^  **fe 


1HI     :* 

HEALTH 
SCIKtfCKS 
blBfUUlY 


l>3 


THE  CITY  LIBRARY  ASSOCIATION 
OF  SPRINGFIELD.  MASSACHUSETTS 
LITERATURE    -    ART    -     SCIENCE 


THE 
CITY  LIBRARY 

SPRINGFIELD 


r**i* 


GIVEN   BY 


aaX-  u 


U6V&1 


MED.  LIB. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clinicalstudiesOOclar 


CLINICAL  STUDIES 
IN  EPILEPSY 


BY 

L.  PIERCE  CLARK,  M.  D., 

Consulting  Physician,  New  York  City  Children's  Hospitals 

and    Schools,    Randall's    Island ;    Letchworth 

Village    for    Mental    Defectives,    and 

Craig  Colony  for  Epileptics 


NEW   YORK 

1917 

G.  E.  STECHERT  &  CO. 

LEIPZIG  LONDON  PARIS 


SUPL.  SOLD, 


librarian 


MED.  LIB. 


Section  I. 

Page 
The  Nature  and  Pathogenesis  of  Essential  Epilepsy,    .       2 

Section  II. 
A  Study  of  the  Epileptic  Makeup,  the  Mechanism  of 
the  First  Attack,  and  Some  of  the  More  Notable 
Life  Reactions  of  an  Epileptic, 45 

Section  III. 
A  Study  Upon  Two  Septs  of  Familial  Epilepsy,  with 
Detailed  Report  Upon  the  Mechanism  in  one  Epi- 
leptic Individual  of  the  Series,        67 

Section  IV. 
Method  of  Graphically  Recording-  the  Mental  Factors 

Precipitating  Epileptic  Reactions,        101 

Section  V. 
Experimental  Study  of    the  Mental  Restoration  of   a 

Deteriorated  Epileptic, Ill 

Section  VI. 
A  Study  of  the  Mental  Mechanism  by  which  Arrests 
Have  Been  Brought   About   in  Several  Cases  of 
Epilepsy, 120 

Section  VII. 
Some  Therapeutic  Suggestions  on  the  Mental  Therapy 
of  Essential  Epilepsy  Deduced  from  Analysis  of  the 
Material  of  this  Clinical  Study, 137 


]  cfifi  ical  stu dies  in  epilepsy. 

By  L.  Pierce  Clark,  m.  D., 

New  York. 

Introdiiction.  The  study  of  essential  epilepsy  by  the  case- 
method  is  here  undertaken  to  show  that  this  disorder  is  a 
logical  sequence  of  a  certain  type  of  individual  make-up  in 
the  process  of  its  natural  development,  and  that  the  varied 
epileptic  reactions  occurring  in  such  individuals  have  more 
or  less  of  a  definite  relationship  to  the  existent  defect  of  in- 
stincts, plus  the  precipitating  causes  which  act  as  psychic 
irritants. 

The  first  section  re-states  the  hypothesis  of  the  nature  and 
pathogenesis  of  essential  epilepsy  with  a  review  of  the  litera- 
ture bearing  upon  this  particular  hypothesis;  then  follows 
some  case  notes  in  abstract  to  illustrate  the  make-up  and 
the  genesis  of  the  first  epileptic  reaction. 

The  second  section  is  based  upon  a  study  of  a  single  case 
to  show  the  ordinary  pathogenesis  of  essential  epilepsy. 
The  third  section  is  another  study  of  the  make-up,  the  en- 
vironmental stresses,  and  the  sequential  epileptic  reactions 
that  occur  in  a  classic,  mildly  deteriorated  individual.  The 
fourth  section  is  a  study  of  two  septs  of  familial  epilepsy 
with  detailed  notes  of  the  pathogenesis  of  fits  in  one 
member.  The  fifth  section  embraces  some  therapeutic 
suggestions  derived  from  the  newer  psychologic  views  of 
essential  epilepsy.  The  sixth  and  last  section  is  devoted  to 
an  analysis  of  several  arrested  cases  of  epilepsy,  and  the 
probable  mechanism  by  which  the  discontinuance  of  the 
disease  was  brought  about. 


THE  NATURE  AND  PATHOGENESIS  OE  ESSENTIAL  EP-JXEESY. 

Two  fundamental  principles  were'brbught  forward  in  my 
first  thesis*  on  the  nature  and  pathogenesis  of  epilepsy: 
First,  that  there  is  invariably  present  an  epileptic  constitu- 
tion or  make-up  in  those  individuals  who  later  develop 
essential  epilepsy.  The  nucleus  of  this  personality  defect 
is  a  temperament  of  extreme  hypersensitiveness  and  egotism 
and  all  that  these  two  main  characteristics  entail.  This 
defect  in  character  is  not  to  be  taken  in  any  narrow  or 
moralistic  sense,  but  is  to  be  considered  as  a  temperamental 
defect  in  a  broad,  biologic  view,  a  personality-defect  which 
makes  its  possessor  incapable  of  social  adaptation  in  its  best 
setting  and  which,  if  it  remain  uncorrected,  renders  the  in- 
dividual entirely  inadequate  to  make  a  normal  adult  life. 
Secondly,  that  the  seizure  phenomenon  in  essential  epilepsy 
is  a  direct  outcome  of  the  inability  of  such  persons  to  sub- 
ordinate their  individualistic  tendencies  to  those  of  the 
so-called  social  demands  and  constitute  a  reaction  away 
from  the  difficulties  in  a  loss  of  consciousness.  In  the  most 
badly  adapted  individuals,  in  which  the  temperamental  de- 
fect is  also  coincident  with  intellectual  and  somatic  defects 
of  a  pronounced  type,  one  may  note  that  even  the  minimum 
of  environmental  stress  may  seemingly  be  lacking,  and  yet 
a  steadily  progressive  epileptic  state  persists.  In  such  the 
epilepsy  attains  its  maximum  frequency  and  severity.  In 
other  individuals  less  afflicted  with  an  adaptational  handi- 
cap, the  disease  of  epilepsy  does  not  appear  until  adolescence, 
or  even  later  when  a  full  adaptive  demand  of  an  independent 
career  is  required. 

Perhaps  it  is  unnecessary  to  say  that  the  nature  of  the  fit 
reaction  is  essentially  a  psychobiological  one,  and  is  doubly 
motivated.  First:  it  is  to  make  away  with  an  intolerable 
adjustment  demand.  Second:  it  is  to  retreat,  to  regress,  to 
a  state  where  harmony  and  peace  were  wont  to  prevail. 
The  most  primitive  pleasurable  state  is  that  which  is  sup- 
posed to  have  existed  before  consciousness  developed,  as 

*N.  Y.  Medical  Jour.,  Feb.  27  to  Mar.  27, 1915. 


has  been  so  correctly  outlined  to  be  the  infantile  and  foetal 
life — a  state  of  metroerotism. 

Inasmuch  as  the  whole  hypothesis  of  the  pathogenesis  of 
the  disease  rests  upon  the  recognition  of  the  particular  type 
of  constitutional  make-up  of  the  epileptic,  I  shall  again 
undertake  to  fully  illustrate  the  psychobiological  features  of 
this  particular  constitution  as  shown  in  a  consecutive  series 
of  actual  case  histories,  which  will  show  the  innate  defect 
and  how  it  reacts  from  a  demanding  environment  in  the 
seizure  phenomena  of  epilepsy.  Obviously  this  thesis  will 
concern  itself  with  the  essential  mechanism  of  classic  idio- 
pathic epilepsy  only.  The  wide  variation  in  the  individual 
pattern,  the  possible  reactions  to  different  types  of  environ- 
mental stress,  etc.,  will  have  to  be  considered  at  another 
time  in  handling  borderland  cases.  This  study  hopes  only 
to  establish  the  main  principle  of  the  essential  epileptic 
temperament  and  its  seizure  reactions. 

A  review  of  the  literature  at  this  point,  tedious  as  it  may 
be,  I  should  have  considered  unnecessary  if  in  many  dis- 
cussions it  had  not  been  specifically  denied  that  there  is  a 
constant  make-up,  or  a  so-called  epileptic  constitution  in  the 
frankly  pronounced  epileptic.  One  also  finds  this  view 
actively  held  in  neurologic  writings,  and  I  therefore  feel 
obliged  to  re-state  the  connoted  opinion  of  some  of  the  more 
important  writers  upon  this  subject.  It  may  be  added  that 
epilepsy,  like  many  another  nervous  disorder  which  lies  in 
the  adjacent  fields  of  neurologic  and  psychiatric  study,  has 
suffered  in  its  complete  delineation  by  the  workers  in  both 
fields,  in  that  each  group  has  ofttimes  misstated  the  different 
symptomatology  not  rightly  belonging  to  the  province  of 
each  other.  For  instance,  if  one  follows  the  psychiatric 
literature  proper,  the  neurologic  charge  against  it  is  that  the 
disease  when  thus  observed  has  had  a  psychiatric  setting 
added  which  was  not  present  in  the  essential  disorder  when 
it  was  observed  neurologically,  and  therefore  such  data 
should  not  rightly  be  interpreted  as  a  necessary  part  of 
the  epilepsy  itself,  but  attributed  to  certain  psychic  elements 
that  apparently  have  arisen  de  novo. 

However,  since  sane  interned  epileptics  have  been  har- 


4 

bored  in  institutions  that  care  for  all  types  and  grades  of 
severity  of  the  disease,  one  finds  that  these  institutional  re- 
ports adhere  closely  to  the  views  of  the  older  psychiatric 
writers  upon  the  constancy  and  degree  of  mental  make-up 
of  the  epileptic  constitution  and  that  the  latter  is  invariably 
present,  though  varying  in  degree,  as  might  be  expected. 

We  may  now  cite  briefly  the  views  of  a  few  authors  taken 
at  random  relative  to  the  epileptic  make-up: 

Vogt*  in  his  work  on  the  psychology  of  epilepsy,  first 
quotes  Sommer  on  the  epileptic  psyche  as  a  total  picture. 
Essentially  he  defines  it  as  shown  in  a  poverty  of  ideas,  pro- 
longed reaction  time,  egocentricity,  many  religious  reactions 
and  acts  of  servility.  All  these  views  were  confirmed  by 
the  studies  of  Fuhrmann,  Bonhbffer,  Krczpelin  and  Isserlin 
as  well  as  the  findings  of  others.  Jung  and  Ritterhaus 
took  up  the  subject  on  a  wider  and  more  precise  basis  of 
psychologic  study;  the  former  investigator  found  a  series  of 
peculiarities  in  the  epileptic  which  also  occur  in  some  degree 
in  normal  subjects,  especially  the  uneducated  class.  There 
was  present  superficial  associations,  which  were  in  part 
influenced  by  the  ideas  of  the  patient.  From  another  view- 
point the  phenomena  resembled  those  seen  in  the  imbecile. 
In  many  cases  the  stimulus  word  called  forth  those 
which  were  nothing  but  explanations;  these  involved  the 
egocentricity,  religiosity,  and  the  like. 

Roemer  having  tested  a  patient  when  he  was  "out  of 
sorts, "  found  a  disturbance  of  "secondary  identification" 
involving  memory  pictures,  etc.,  while  primary  (special 
sense  recognition)  remained  normal.  Einti?iger  found  a 
fewness  in  all  associations  or  oligophasia,  with  persevera- 
tion and  reiteration;  all  of  these  pointed  to  an  essential 
poverty  in  the  affectivity.  Wiersma  found  periodical  vari- 
ations in  attentiveness.  Finally,  Ritterhaus  sums  up  the 
epileptic  psyche  as  follows:  There  is  a  narrowing  of  the 
circle  of  ideas;  there  is  prolongation  of  reaction  time,  ego- 
centricity, emotional  reactions  and  circumstantiality.  The 
preceding  results  lose  somewhat  in  value  as  but  relatively 
few  epileptics  were  tested. 

Vogt  states  that  while  we  are  justified  in  isolating  major 

*Vogt,  "  Psychology  of  Epilepsy"  in  Ascliaffenburg's  Handb.  d.  Psychiatrie. 


interval  phenomena,  the  mildest  forms  simply  represent  an 
alteration  of  the  total  personality.  When  this  is  carried  to 
a  higher  degree  we  speak  of  the  epileptic  character  (  de- 
veloped from  the  alteration) ;  beyond  this  "character"  we 
find  the  epileptic  psychosis.  Vogt  declares  that  the  "  epilep- 
tic character  "  is  a  peculiar  mixture  of  psychic  components 
which  are  mutually  antagonistic.  Obstinacy  and  contrari- 
ness may  exist  with  a  high  degree  of  docility,  apparently 
based  on  change  of  moods.  Mendacity  and  ethical  perver- 
sions may  be  seen  with  piety  and  pleasing  speech;  openness 
contrasts  with  distrust;  misanthropy  with  a  childlike  cheer- 
fulness. Through  all  this  variegated  expression,  however, 
one  notes  a  general  tendency  to  a  severeethical  degeneration. 
The  subject  becomes  unsocial,  quarrelsome,  is  inclined  to 
lie  and  employ  violence.  Hence  the  great  forensic  importance 
of  the  "character." 

The  intellectual  faculties  strictly  as  such  may  remain  in- 
tact during  the  development  of  the  character;  until  the  epi- 
leptic psychosis  develops  with  its  well  known  intellectual 
failure.  This  is  naturally  accompanied  by  persistence  of 
the  character  changes — the  piety,  the  narrowing  of  the 
horizon  to  self  and  family,  the  emphasis  of  trifles,  and 
the  lack  of  judgment.  The  patient  undervalues  his  disease 
and  his  mental  state  as  he  magnifies  his  own  importance 
and  becomes  arrogant,  etc.  Vogt  finally  adds  that  in  de- 
pressed moods  the  affects  are  one-sided,  monotonous  and 
superficial;  or  they  are  irritable  and  manifold.  They  are 
sensitive,  feel  uncomfortable,  are  whimsical  and  '  know  it 
all; '  they  show  great  obstinacy,  distrust,  and  are  inclined 
to  outbreaks  of  rage.  Their  intense  irritability,  their  utter 
disregard  and  tendency  to  violence,  make  them  the  most 
difficult  and  least  welcome  in  institutions.  The  instan- 
taneous change  of  mood  is  largely  responsible  in  this 
respect. 

Again,  under  "epileptic  insanity,"  Krcepelhi*  described 
in  full  a  case  which  seems  to  be  only  an  exaggerated  in- 
stance of  epileptic  alteration  with  twilight  states.  No  true 
psychosis  was  mentioned.  The  first  case,  an  epileptic  alco- 
holic, exhibited  much  of  the  "character;  "  but  the  peevish- 

♦Kraepelin,  ''Lectures  on  Clinical  Psychiatry,"  Am.  ed.,  1913. 


ness,  irritability,  etc.,  might  be  attributable  to  the  alcohoL 
The  patient  seemed  driven  to  rage  and  violence  by  severe 
pains  and  other  physical  symptoms.  These  phenomena 
seemed  to  appear  in  spells,  the  patient  showing  great  de- 
pression which  in  turn  led  him  to  drink.  He  had  attacks 
of  ill- humor  every  week  or  two.  The  patient  was  normally 
egotistic  and  pietistic,  and  boasted  much  of  his  military 
achievements  (an  old  soldier).  He  looked  down  on  all 
other  men,  could  do  every  man's  work  better  than  the  man 
himself;  he  was  ceremoniously  polite,  saluted  the  doctor  on 
every  occasion — but  also  expected  a  salute  in  return.  He 
took  great  pleasure  in  saying:  "The  good  God  never  for- 
sakes a  German."  This  patient  improved  when  alcohol 
was  withdrawn.  Another  patient  was  most  of  the  time 
friendly,  easy  to  manage,  and  quiet,  but  had  frequent  spells 
of  depression  and  ill-humor,  with  great  irritability.  He 
stated:  "I  have  times  when  I  am  not  at  all  irritable,  and 
then  again  times  when  I  get  wild  at  every  trifle."  This 
second  case,  according  to  Kraepelin,  had  not  yet  developed 
the  character;  when  he  did,  the  author  believed  the  patient's 
horizon  would  narrow,  he  would  become  egotistical  with  an 
exaggerated  self-esteem,  and  have  a  tendency  to  phrases 
and  pious  saws.  Another  patient  gave  a  "  connected  but 
long-winded"  account  of  his  past  and  present  status.  He 
spoke  of  joyous  moods.  He  had  had  states  of  great  ex- 
citement and  had  committed  crimes  against  property  and 
person.  This  patient  was  an  alcoholic.  He  had  about 
everything  sooner  or  later,  including  a  "visit  to  Heaven  " 
which  Kraepelin  ascribed  to  the  influence  of  alcohol. 

In  summarizing  the  epileptic  character,  Arndt*  states, 
that  he  is  possessed  with  an  inward  fervor  manifested  as 
love  or  religion.  The  latter  was  throughout  egotistic,  which 
explained  in  part  the  epileptic  moment  which  was  a  mix- 
ture of  cold  calculation,  regardless  hardness  (callousness), 
cruelty,  malice,  piety,  etc.  Nevertheless,  side  by  side  with 
a  diabolical  irritability  and  irascibility,  with  uneasiness,  dis- 
trust, 'know-it-all-ness,'  obstinacy,  stupidity  and  desire  for 
mastery,  he  shows  docility,  obsequious  and  flattering  be- 
havior, and  self-depreciation.     The  fire  of  epilepsy  is  like 

♦Arndt,  "Lehrbuchd.  Psychiatrie,"  1883. 


enthusiasm,  in  the  interest  of  revenge  and  bloody  atone- 
ment. In  the  epileptic  character  there  is  something  violent 
and  titanic.  Very  characteristic  of  epilepsy  is  attachment 
to  the  family  (as  a  whole,  not  perhaps  to  individual 
members);  they  sing  the  family's  praises,  not  forgetting 
themselves;  and  Morel  stated  that  self-praise  was  a  sign  of 
the  epileptic  character.  Arndt  believes  that  the  alcoholic 
character,  especially  the  dipsomanic  type,  strongly  re- 
sembles the  epileptic.  There  is  the  same  blunt  egotism,  in- 
difference to  wife  and  children;  the  same  reaction  to 
irritation,  etc. 

While  BianchVs  view*  of  the  epileptic  character  is  neces- 
sarily drawn  from  the  statistics  of  a  people  highly  unstable 
emotionally,  it  is  nevertheless  quite  in  accord  with  those 
given  before;  thus,  speaking  of  the  psychic  disturbance  in 
epileptics  he  rightly  holds  that  it  is  always  present  in  essen- 
tial epilepsy,  and  that  the  latter  properly  begins  with  the 
epileptic  character.  This  is  inherited  or  acquired,  more 
frequently  the  former,  and  manifests  itself  at  an  early  age, 
or  as  soon  as  the  infant  realizes  its  relationship  to  the  family. 
The  child  is  less  bright,  i.e.,  more  dull,  than  normal.  It 
weeps  much  and  without  cause,  and  over  long  periods,  even 
until  cyanosed.  It  persists  in  all  exaggerated  and  ca- 
pricious desires,  despite  attempts  to  reason  with  it.  It 
reacts  by  scratching  its  face,  breaks  objects,  raises  its  voice, 
stamps  its  feet,  threatens,  etc.  When  to  these  are  added 
sleep  disorders — nightmares,  terrifying  dreams,  somnam- 
bulism— the  character  is  perhaps  developing  into  epileptic 
seizures. 

In  favorable  cases  these  symptoms  are  outgrown;  in  un- 
favorable cases  the  subjects  are  beyond  treatment.  The 
morbid  character  undergoes  a  hypertrophy  of  the  ego.  In 
childhood  and  adolescence  the  epileptic  character  in  one  of 
its  groups  closely  resembles  the  moral  character  of  the 
antisocial  instincts  of  the  criminal.  There  is  the  same 
inadaptability  to  environment,  the  preponderance  of  in- 
dividualistic instinct,  the  cruelty,  laziness,  vagabondage, 
evil  life,  precocious  and  excessive  character  of  the  sexual 
instinct,  irascibility  and  impulsiveness  in  both.     If  at  ado- 

•L.  Bianchi,  "Textbook  on  Psychiatry,"  1906. 


8 

lescence  there  are  no  convulsions,  the  subject  must  be 
regarded  as  a  criminal  (save,  perhaps,  when  there  is  a 
history  of  infantile  convulsions).  In  another  group  the 
personality  is  less  profoundly  disturbed.  These  seem  nor- 
mal, well-behaved  children  in  the  home;  when  they  leave 
for  boarding  schools,  etc.,  an  anomalous  character  devel- 
ops, due  largely  to  the  teasing,  chaffing,  etc.,  of  which 
they  are  victims.  They  now  show  excessive  irritability, 
suspicion,  impulsiveness,  irascibility — in  other  words,  they 
act  excessively  to  their  environment.  The  more  they  change 
the  greater  objects  they  become  for  provocation.  The  sub- 
jects now  begin  to  threaten,  and  have  to  be  sent  home,  even 
if  no  convulsion  appear. 

As  maturity  is  approached,  further  changes  of  character 
appear.  The  epileptic  isolates  himself,  avoids  company 
and  conversation  and  at  the  same  time  turns  to  religion,  or 
rather  the  outward  forms  of  it.  He  goes  to  church  daily 
and  at  home  says  prayers  and  chants.  He  becomes  ex- 
cessively humble — meek  and  submissive  to  those  whom  he 
meets.  He  assumes  an  attitude  of  in  feriority  and  an  humble, 
reverent  pose.  Beneath  all  this,  however,  he  is  irascible, 
captious,  violent,  impulsive  and  cruel.  A  slight  cause 
given,  and  the  mask  is  at  once  thrown  off. 

Irascibility  and  impulsiveness  are  then,  in  Bianchi's 
opinion,  the  chief  features  of  the  epileptic  personality ; 
epileptics  lose  self  control  completely  at  the  least  opposition. 
Their  violent,  obstinate  desires  are  too  overpowering  to  be 
resisted,  hence  the  egotism.  But  there  must  be  defect  in 
the  associative  work  of  the  brain.  Malice  is  based  on  two 
fundamental  sentiments, — consciousness  of  inferiority  to 
others  causes  hatred  and  suspicion  ;  and  contrariness,  from 
permanent  irritability  of  the  ego.  The  whole  life  of  the 
epileptic  shows  hatred,  usually  concealed  and  veneered, 
perhaps,  with  good  behavior.  On  the  slightest  provocation 
the  hatred  bursts  forth  in  all  its  brutality — all  that  is  evil, 
deadly,  destructive  is  revealed  to  the  mind  of  the  subject, 
although  it  may  not  be  betrayed  in  actual  display.  The 
religious  sentiments  are  highly  primitive,  mystical  and 
ceremonial.     Prejudiced    against  so  many  things  as   they 


are,  these  subjects  easily  abandon  themselves  to  onanism, 
sexual  excesses  and  perversions,  alcoholism,  etc. 

The  father  of  the  epileptic  Misdea  is  cited  by  Bianchi  as 
one  who  was  not  himself  an  epileptic  but  showed  the  most 
profound  features  of  the  epileptic  character.  He  used  to 
curse  his  brother  priests  because  they  did  not  walk  properly 
to  chapel  or  carry  out  his  orders  to  the  letter. 

They  like  wine  (Bianchi  is  describing  Italians),  and  a 
little  of  it  awakens  their  brutality.  Then  they  become  ex- 
acting, egotistic,  captious,  obscene,  cynical,  impulsive  and 
cruel.  The  remarkable  mobility  and  contrasts  suggest 
double  personality  ( Lombroso) .  Some  epileptics,  exclud- 
ing the  imbecilic,  are  not  so  nearly  normal  as  they  appear. 
Many  learn  trades  and  professions,  but  are  weak  on  the 
affect  side.  Keenness  of  attention  to  every  day  realities  is 
subnormal,  and  this  is  responsible  for  minor  automatisms, 
such  as  day  dreaming,  absent-mindedness  and  various  atti- 
tudes of  preoccupation. 

One  must  remember  that  Bianchi  is  not  writing  of  epi- 
leptic imbeciles  or  dements,  but  of  quasi  normal  subjects — 
their  perceptions  are  weak  and  the  memory  is  not  trust- 
worthy. Ideation  is  variable.  They  are  indifferent  to  all 
that  does  not  concern  them.  Grandiose  ideas  are  common 
with  mystic  ones,  and  ideas  of  persecution  are  ill  defined 
and  fleeting  (paranoidism). 

In  regard  to  the  better  class  of  epileptics  Bianchi  has 
never  seen  a  superior  intellect  and  character  in  hundreds  of 
cases  treated. 

It  would  appear  that  a  full  recognition  of  an  epileptic 
constitution  as  such,  independent  of  the  deteriorating  influ- 
ence of  excessive  attacks  which  only  brings  it  more  mark- 
edly in  view,  was  not  much  recognized  before  1860  or  1870; 
thus  Fafret  the  elder,  an  observer  of  about  that  time,  and 
Billod  (1882)*,  a  pupil  of  Falret,  as  well  as  Kirchhoff^ 
who  wrote  as  late  as  1890,  believed  that  the  peculiar  mental 
make-up  of  so-called  sane  epileptics  did  not  possess  mental 
characteristics  distinguishable  from  others  in  their  particu- 
lar station  in  life. 

*  E.  Billod,  "  Des  Maladies  Mentales  et  Nerveuses,"  1882. 
+  Kirchhoff,  "Handbook  of  Insanity,"  Am.  ed.,  1893. 


10 

It  is  interesting  to  note  the  view  which  a  practical  neu- 
rologist would  have  upon  the  presence  of  a  particular  and 
distinctive  constitutional  make-up.  Oppenheim* \  a  neu- 
rologist of  this  type,  states  that  the  intellect  of  an  epileptic 
may  be  "absolutely  intact."  He  cites  the  examples  of 
Caesar  and  Napoleon,  but  quickly  adds  that  we  see  no  such 
cases  to-day.  In  another  division  of  his  work  he  states 
that  sane  epileptics  are  "often  excitable,  suspicious  and 
irascible"  but  hastens  to  offer  an  apology  based  upon  the 
nature  of  the  disorder  from  which  they  suffer.  He  finally 
adds,  however,  that  a  normal  intellect  becomes  impaired 
by  the  fits. 

As  soon  as  the  defects  in  the  affect  were  recognized  in 
psychiatry  independent  of  purely  intellectual  ones,  a  nota- 
tion of  the  former  began  to  appear  in  the  literature  of  the 
psychology  of  epilepsy.  Thus  Hoche^  noted  that  epilep- 
tics undergo  disturbances  of  the  affects  as  well  as  in  their 
intellectual  life.  When  the  former  are  of  a  certain  inten- 
sity they  are  known  as  the  psychic  epileptic  degeneration. 
In  the  foreground,  occurring  mostly  in  exacerbations,  we 
find  excessive  excitability,  oversensitiveness,  whimsicality 
and  attacks  of  rage  from  trifling  causes.  Such  states  are 
really  persistent,  but  have,  as  stated,  a  certain  periodicity. 
The  psychic  interests  become  narrowed,  especially  in  the 
ethical  aspects.  There  now  develops  the  peculiar  behav- 
ior— absence  of  affection,  egotism,  entire  preoccupation 
in  self,  regardless  of  the  rights  of  others,  obstinacy,  false 
imaginations  of  being  snubbed,  and  accusations  based 
thereon.  With  self  satisfaction  may  be  associated  family 
pride,  bigotry,  piety,  etc. 

"Epileptic  degeneration"  is  a  term  restricted  to  the 
worst  of  these  cases  ;  in  mild  cases  we  see  in  most  cases 
only  the  "epileptic  character." 

Occasionally  as  early  as  1887  the  dissociation  between 
the  epileptic  constitution  and  the  mental  changes  brought 
about  as  the  result  of  the  attacks  is  to  be  noted  in  studies 
on  epileptics.     Thus  SeeligmiillerX  quotes  Nothnagel  to  the 

•Oppenheim  (translated  by  Bruce),  "Textbook  on  Nervous  Diseases,"  1911. 
tHoche,  "Handb.  d.  gerichtlichen  Psychiatrie,"  1901. 

$Seeligmuller,   "  Lehrbuch  d.  Krankheiten  d.  Ruckenmarks  und  Gehirns," 
etc.,  1887. 


11 

effect  that  two  widely  different  conditions  are  to  be  consid- 
ered here,  viz.:  the  central  epileptic  alteration,  and  the 
attacks.  The  former  is  inherited,  and  due  to  descent  from 
those  with  neuropathic  and  other  taints,  etc.  With  this 
author  "alteration"  appears  synonymous  with  "predispo- 
sition ";  it  does  not  mean  dementia  or  secondary  changes. 
Under  " iuterparoxysmal  pause"  we  find  here  as  with 
other  authors  phenomena  described  which  represent  second- 
ary alteration.  The  epileptic  is  a  misanthrope,  to  a 
greater  or  less  extent;  he  is  habitually  out  of  sorts,  is  irri- 
table, distrustful,  obstinate,  irascible,  etc.  At  times,  and 
often  near  attacks  he  is  unnaturally  cheerful.  This  the 
author  regards  as  wholly  due  to  the  unfortunate  social 
status  of  the  epileptic,  his  dependence  on  others,  his  loneli- 
ness. Even  the  wild  outbreaks  of  rage  and  destructiveness 
may  be  due  to  the  hate  of  all  people  who  are  normal. 

In  recognizing  the  preconvulsive  make-up  of  the  epileptic 
constitution  and  citing  first  the  egocentricity  and  hyper- 
sensitiveness  as  the  essential  mental  features  of  the  picture, 
and  later  the  occurrence  of  obsequiousness,  effusiveness 
and  sweetness,  Regis*  notes  that  the  latter  were  but  the 
natural  outward  adjustments  to  compensate  for  the  inner 
repressed  feelings. 

Now  and  then  one  finds  in  the  neurological  literature  as 
in  contradiction  to  the  psychiatric  or  psychologic  view,  an 
attempt  to  find  an  organic  basis  for  the  epileptic  make- 
up just  as  we  have  seen  some  authors  strive  to  see  many  of 
the  mental  characters  produced  by  the  social  restrictions 
which  the  interned  epileptic  endures  as  a  result  of  his 
malady.  Thus  Cramer^,  while  firm  in  the  belief  that  epi- 
lepsy proceeds  from  cortical  alterations,  becomes  confounded 
and  unable  to  explain  the  constitutional  make-up  by  such 
changes.  However,  in  an  attempt  to  rationalize  the  latter 
he  finds  certain  evidence  of  a  particular  form  of  abnormal 
excitability  of  the  nerve  centers  of  the  cerebrum  as  a 
result  of  which  discharges  result  from  the  summation  of  a 
"subminimum  irritation",  there  being  inconsequence  an 

t  Regis,  "  Precis  de  Psychiatrie,"  1909. 

X Cramer,  "Die  Epilepsie,"  Handb.  d.  Nervenkrank.  im  Kindesalter  (Brunsr 
Cramer  &  Ziehen),  iyi2. 


12 

inclination  to  react  by  convulsions  in  such  individuals. 
Again,  such  a  "character"  is  subject  to  disorders  of 
metabolism.  He  adds  that  many  persons  with  the  consti- 
tution never  really  become  epileptic  as  the  precipitating 
causes  are  not  applied  to  such.  This  author  lays  down  the 
character  make-up  as  shown  by  the  same  behavior  and  con- 
duct as  outlined  by  Vogt  and  others.  While  he  is  willing 
to  admit  the  foregoing  is  the  invariable  rule  for  the  psyche 
of  adult  epileptics,  he  takes  marked  exception  that  it  exists 
in  childhood.  He  claims  to  have  seen  well  developed  cases 
of  epilepsy  in  the  young  withoiit  a  trace  of  psychopathic 
make-up.  He  states,  without  definite  analysis  of  any  case 
material,  that  he  has  an  entire  series  of  cases,  chiefly 
drawn  from  the  upper  classes  of  society,  in  which  epilepsy 
occurred  in  "model  children."  In  school  they  were 
among  the  first  in  their  classes.  We  may  interpolate  here 
to  say  that  one  knows  only  too  well  how  clever  and  devoted 
parents  carefully  shield  such  children  from  a  too  precise 
character  analysis.  Our  author  seems  willing,  however,  to 
admit  that  such  children  begin  to  show  the  epileptic  con- 
stitution toward  the  end  of  puberty — an  analogously  easy 
place  for  many  observers  to  note  the  beginnings  of  many 
another  neurosis  and  psychosis.  A  double  substratum 
of  degeneracy  and  epilepsy  is  postulated  by  our  author  for 
a  "very  large  group  "  of  children  who  have  the  character 
and  later  develop  epilepsy,  and  then  follows  the  general 
description  of  the  well  outlined  constitution  of  our  conten- 
tion. Our  author's  degeneracy  picture  is  held  out  of  the 
epileptic  entity, — he  says  it  "can  not  be  regarded  as  any 
part  of  the  early  stage  of  the  after-coming  malady." 

Nearly  all  authors  agree  that  the  drug  habitues  and  dip- 
somaniacs have  an  identical  constitution  and  often  more 
marked  than  that  seen  in  the  epileptic. 

Under  the  heading  of  "epileptic  temperament,"  Turner* 
notes  it  is  rare  to  find  epileptics  without  some  mental  ob- 
liquity, and  even  when  slight  and  unobtrusive  is  a  feature 
of  their  hereditary  degeneration.  On  the  whole  they  are 
self-opinionated  and  egotistical,  have  a  high  degree  of  con- 
ceit  and   assurance.      Their    talk    is   usually    prolix    and 

*A.  Turner,  "  Epilepsy,"  1907. 


13 

pretentious.  The  character  is  mobile  and  unstable,  and 
they  are  now  elated,  now  despondent.  This  affects  their 
mental  processes.  Other  epileptics  are  tenacious  and  obsti- 
nate and  have  strong  likes  and  dislikes.  Some  "great" 
epileptics  seem  to  have  owed  their  greatness  to  grand  ideas 
and  tenacity.  The  majority  of  epileptics  are  religious  in 
strong  contrast  with  their  practical  ethical  standards. 

Among  the  phenomena  of  latent  epilepsy  Harlmann  and 
di  Gaspero*  believe  that  long  before  the  epileptic  symptom 
complex  with  its  first  undoubted  paroxysmal  phenomena 
becomes  manifest,  an  individual  may  show  prodromes,  the 
relationship  of  which,  however,  to  epilepsy  can  not  be  main- 
tained with  certainty.  They  cite  many  variations  in  affect 
life  in  getting  family  histories  of  epileptics,  and  find  such 
are  hardly  ever  missing  from  such  histories.  Here  belong 
the  tendencies  to  abnormal,  endogenous  changes  of  temper, 
excitations  of  irascible  nature,  anxious  fears  and  sudden 
depressions.  Aside  from  the  sequalae  and  prodromes  of  an 
attack,  the  authors  mention  marked  exhaustibility,  rest- 
lessness, anomalies  of  disposition,  increased  irritability, 
distrust,  depression,  anxious  fears,  tendency  to  violent  im- 
pulses. In  addition  to  the  usual  slight  mental  defects,  the 
authors  note  a  tendency  to  unreal  ideas.  There  are  also 
memory  falsifications.  The  affect  life  as  a  rule  shows  great 
departures.  There  are  transitory  phobias,  ecstasies,  and, 
most  common  of  all,  irritable  and  depressive  states.  As 
high  as  78  per  cent  are  said  to  suffer  from  these  endogeneous 
anomalies  of  disposition.     As  a  rule  consciousness  is  clear. 

Under  the  progressive  deterioration  seen  in  advanced  cases 
of  epilepsy,  the  authors  refer  to  the  deterioration.  As  a  rule 
the  subjects  react  abnormally  to  external  impressions.  The 
affective  changes  constitute  that  ethical  depravity  of  the  en- 
tire personality  known  as  the  epileptic  character.  We  see 
here  a  morbidly  augmented  irritability  of  the  temper,  with 
a  special  tendency  to  affect  outbreaks  of  anger.  The  pa- 
tients are  regardless,  often  aggressive.  An  egocentric 
contraction  of  the  entire  emotional  life,  pathological  lying, 
etc.,  may  develop.  The  patients  are  hard  to  manage,  irre- 
sponsible, unsteady,  and  without  definite  aim.     They  are 

♦Hartmann  and  di  Gaspero,  ••  Epilepsie,"  Lewandowsky's  Handbuch,  1914. 


14 

obstinate  but  may  show  a  heightened  sensibility.     These 
states  gradually  pass  on  to  dementia. 

Gelineaift  and  Griesi?iger\  both  dilate  at  length  upon  the 
essential  continuity  of  the  primary  epileptic  constitution,  its 
egocentric  and  hypersensitive  characteristics  and  its  ulti- 
mate degeneration  into  the  classic  mental  make-up  noted  in 
previous  authors.  The  latter  mentions  the  labile  affecta- 
bility to  be  inherent  and  to  exist  for  years  before  the  malady 
as  such  develops;  further,  that  the  slightest  demands  of  an 
exacting  environment  cause  all  the  mental  characteristics 
to  show  themselves  on  the  surface.  The  former  author 
(Gelineau)  cites  numerous  cases  in  which  he  believes  over- 
work to  have  caused  the  disease.  But  his  views  are  quite 
understandable  on  psychologic  grounds  where  we  find  that 
the  stress  of  disagreeable  work,  beyond  the  desire  or  ca- 
pacity of  the  individual,  produces  "moral  perturbations, 
disequilibrations,  and  finally  convulsions."  His  comment 
on  the  instances  are  that  the  overwork  seems  to  be  the  result 
rather  by  reason  of  the  fact  that  the  individual  does  his 
work  with  certain  "  overscrupulosity  "  and  feels  an  inability 
to  reach  desired  results.  One  patient  in  particular  who  was 
a  writer  had  his  overwork  induced  by  writing  and  re- writing 
a  sentence  "over  and  over,  seeking  for  a  more  euphonious 
expression." 

Voisin  has  stated  that  every  epileptic  is  original,  fantas- 
tic and  difficult  to  live  with,  and  that  in  a  careful  analysis 
of  the  character  make-up  of  one  hundred  and  forty-eight 
cases  of  so-called  mentally  sound  epileptics  less  than  10  per 
cent  showed  a  perfect  balance  in  the  emotional  make-up. 
The  intellectuality  in  all  these  cases  was  normal  or  even 
above  the  average.  Continuing  their  own  investigations 
Grasset  and  RauziesX  came  to  the  conclusions  that  no  epi- 
leptic was  of  sound  mind.  It  is  false  to  declare,  however, 
that  they  are  ' '  alienated  in  the  ordinary  sense. ' '  Their  defect 
is  in  the  emotional  realm,  they  are  essentially  egocentric  and 
hypersensitive  individuals  and  are  so  in  some  measure  from 
birth.     In  describing  the  ordinary  mental  state  and  charac- 

*  T.  B.  Gelineau,  "Traite  des  Epilepsies,"  1901. 
tGriesinger,  "  Psychische  Krankheiten,"  5th  ed..  1892. 

Grassetif  and  Rauzies,  "Traite  pratique  d.  mal.  d.  systeme  nerveux."  Vol.  ii, 
1894. 


15 

ter  of  epileptics  in  a  large  number,  Fere*  believed  that 
the  character  and  manner  of  epileptics  can  easily  cause 
suspicion  of  the  disease  long  before  the  convulsions  appear. 
The  emotional  make-up  is  mobile  and  explosive,  the  former 
rests  upon  a  foundation  of  "impotence  and  sadness." 
They  may  change  in  mood  so  suddenly  as  to  resemble  a  dra- 
matic coup.  Long  periods  of  calm  are  interrupted  by  brief 
periods  of  mobility.  In  others  the  latter  is  constant. 
Paroxysms  are  separated  only  by  intervals  of  repair.  Sub- 
jects pass  from  an  attitude  of  enthusiasm  and  benevolence 
into  one  of  implacable  hate.  They  may  be  tender  and 
generous,  and  then  show  sordid  rapacity  and  violence. 
They  may  now  be  polite  and  obsequious,  then  all  at  once 
insolent,  or  may  be  gay  and  expansive,  then  taciturn.  Some- 
times the  change  is  in  the  mental  processes.  A  submissive 
subject  suddenly  becomes  an  obstinate  adherent  to  a  cer- 
tain idea.  The  matter  may  be  ever  so  petty  but  he  can  not 
be  reasoned  out  of  it.  The  epileptic  is  not  always  change- 
able. He  may  become  permanently  attached  to  certain 
people  or  he  may  cherish  certain  ideas  and  purposes  with 
most  extraordinary  tenacity — such  as  is  seen  in  "great" 
men.  (In  point  of  fact,  this  is  the  rule.)  Violence  and 
explosiveness  may  be  contrasted  with  the  following  periods 
of  depression  and  amnesia.  This  depression  is  the  real 
cause  of  moral  malaise,  religiosity,  pessimism,  and  jealousy 
(very  common).  Insolence  and  cruelty  often  pass  into  ob- 
sequiosity  and  panphobia  and  are  thought  by  Fere  to  be 
due  to  jealousy,  for  the  epileptic  realizes  his  helplessness 
and  defects  in  a  vague  manner. 

Matter  equally  pertinent  is  that  mentioned  by  Ardin- 
Delteil\  in  his  study  of  the  epileptic  psyche,  that  the  men- 
tal affectivity  is  a  basis  of  defect  in  epileptics.  The  epilep- 
tic is  in  a  state  of  mental  hyperesthesia  which  exaggerates 
sensations  and  the  ideas  derived  from  them  and  which  cause 
irresistible  acts  (Echeverria) .  It  seems  that  in  these  brains 
there  is  always  a  certain  virtuality  of  explosion,  ' '  a  deep 
and  deaf  irritation  of  which  the  convulsion  is  the  maximum 
term."     The  epileptic  finds  himself  in  a  constant  state  of 

♦Fere,  "  Les  Epilepsies  et  les  Epileptiques,"  1890. 
tArdin-Delteil,  "  L'Epilepsie  Psychique,"  1898. 


16 

nervous  tension,  revealed  by  instability,  petulence,  perver- 
sion of  sentiments,  hyperesthesia,  promptness  to  motion. 
Like  a  drop  which  causes  a  full  vase  to  run  over,  any  slight 
cause,  material  or  mental,  leads  up  to  the  explosion.  The 
"potential"  accumulates  until  a  discharge  results,  and  a 
multiplicity  of  insults  may  hasten  it.  This  increase  of  po- 
tential gives  rise  to  a  certain  irritability  which  always  lies 
at  the  foundation  of  every  epileptic  character.  Another 
constant  is  instability.  While  the  extreme  irritability 
(Hack  Tuke,  Bucknill)  is  rapidly  transformed  into  impuls- 
ive acts,  against  others  or  one's  self,  the  instability  makes 
of  the  epileptic  a  being  who  is  capricious — in  the  morning 
perhaps,  lively,  gracious,  enthusiastic,  satisfied;  and  later 
in  the  day,  sad,  despairing,  disgusted  with  life,  depressed, 
religious  (Clouston,  Schiile,  Falret) .  There  is  therefore  a 
veritable  specific  epileptic  character  defined  by  the  vari- 
ability and  intermittence  of  mental  dispositions.  Whence 
proceed  these  tendencies  toward  rupture  of  the  mental  and 
moral  equilibrium?  Having  discussed  heredity  as  the 
source  of  this  character,  the  author  asks  how  may  the  latter 
be  recognized  ?  It  is  betrayed  by  intense  affectivity,  by  a 
real  failure  of  the  moral  sense.  Candidates  of  epilepsy  as 
well  as  actual  epileptics  are  egotists,  distrustful,  irascible, 
violent,  impetuous,  malicious,  knavish,  with  exaggerated 
or  simulated  religion  and  piety,  and  prone  to  excesses. 
Their  moods  are  bizarre,  contradictory,  subject  to  frequent 
and  rapid  changes.  These  unbalanced  persons  whose 
dominant  note  is  irascibility  and  irritability  appear  as  the 
incarnation  of  vice  and  cruelty.  In  all  cases,  the  moral 
sense  is  almost  constantly  attacked  as  shown  by  egoism,  in- 
difference to  the  rights  of  others  and  absence  of  remorse. 
The  homicide  has  not  a  word  of  compassion  for  his  victim. 
Crimes  are  done  with  the  greatest  cynicism  and  cold  blood. 
The  murderer  remains  near  his  victim  or  goes  about  his 
occupation  as  if  nothing  had  happened.  The  child  who  is 
to  be  an  epileptic  is  vicious,  already  irritable  and  impulsive. 
His  motives  are  futile,  he  isolates  himself  or  runs  away,  and 
has  sombre  ideas.  At  the  slightest  reprimand  he  speaks  of 
suicide,    or    absents    himself    for    days    after   a   chiding. 


17 

He  is  sexually  precocious,   an  onanist,  has  night  terrors, 
somnambulism,  etc. 

In  his  work  on  mental  affections,  Macphersori* ,  states  in 
regard  to  the  make-up  of  the  epileptic,  that  the  general 
mental  state  is  distinctive,  although  many  during  the  inter- 
paroxysmal  period  seem  quite  normal  and  attend  to  their 
business  affairs.  Even  in  the  "so-called"  insane  and  de- 
generate epileptics  the  intervals  may  show  but  these  same 
oddities  and  eccentricities  of  conduct,  want  of  self-control 
and  instability  of  emotions.  Most  of  these  cases  are  hypo- 
chondriacs taken  up  entirely  with  themselves,  their  bodies, 
etc.,  and  also  their  passions,  feelings  and  sentiments. 
They  exaggerate  mild  ailments,  constantly  demanding 
attention.  They  are  usually  vain,  self-laudatory  and  nar- 
row-minded, although  at  the  same  time  usually  obsequious 
and  agreeable.  While  kind  and  sympathetic  with  one 
another,  especially  when  their  fellow  patients  have  fits, 
they  also  quarrel  fiercely  among  themselves.  They  mostly 
profess  religion  and  observe  its  forms  ostentatiously,  and 
many  are  really  sincere.  Their  characteristic  is  also  seen 
in  degeneracy  as  is  also  egotism,  etc.  Nearly  all  are  pas- 
sionate, and  when  angered  are  furious.  They  have  no 
self-control  and  hence  indulge  in  alcohol,  sexual  excesses, 
indecent  behavior,  etc. 

Anyone  acquainted  with  the  well-formed  peculiar  mental 
characteristics  of  the  frank  epileptic  in  institutional  life  will 
easily  recognize  the  classic  description  of  the  epileptic 
make-up  as  given  by  Pilcz*  when  he  states  the  following: 

In  relating  anything  the  epileptic  is  never  diverted  and 
always  arrives  at  a  conclusion.  He  repeats  the  same  story 
in  the  same  language,  and  makes  free  use  of  commonplaces, 
proverbs,  and  biblical  texts.  As  a  rule  they  are  pietists,, 
observe  religious  duties  scrupulously.  Their  devotion  is  at 
times  exaggeratedly  sweet.  They  flatter  by  frequently  pre- 
fixing "good"  and  "kind"  in  addressing  others.  In 
striking  and  characteristic  contrast  to  the  foregoing  is  the 
unusually  marked  irritability,  sensitiveness  and  egotism. 
The  patient  who  assures  ' '  his  dear  doctor ' '  that  he  will 

♦Macpberson,  "Mental  Affections,"  1899. 
fPilcz,  "Lebrb.  d.  spez.  Psychiatrie,"  1904. 


18 

remember  him  in  his  prayers,  will  insult  him  by  word  or 
deed  if  he  thinks  he  is  being  slighted  in  any  way.  They 
are  almost  pedantically  methodical  in  institutions,  to  which 
they  bring  all  their  knick-knacks  and  presents,  which  are 
carefully  and  neatly  packed.  These  they  carry  with  them 
and  keep,  moreover,  a  sort  of  inventory.  Handwriting  is 
painfully  correct,  ornamental,  old-fashioned,  etc. 

Finally,  we  may  cite  the  views  af  H'ubner  who,  in  a  care- 
ful analysis  of  the  mood  or  disposition  of  the  epileptic, 
states  that  as  a  rule  these  set  in  with  no  disturbance  of 
consciousness.  The  patients  seem  out  of  sorts,  taciturn  and 
isolate  themselves.  If  one  makes  up  to  them  they  are  gruff, 
and  refuse  to  respond.  At  the  very  first  opportunity  they 
pick  a  quarrel  with  someone.  In  institutions  they  complain 
of  the  food,  demand  their  discharge,  behave  disagreeably 
to  other  inmates  and  keepers  whom  they  regard  as  preju- 
dicial to  them.  The  facial  expression  is  gloomy  and 
repellant,  and  they  are  restless  and  on  the  go.  This  spell 
may  be  a  matter  of  hours  or  days.  After  it  has  passed  the 
patient  gives  a  good  account  of  himself,  says  he  has  been 
ill,  how  everything  trifling  was  able  to  irritate  him.  There- 
fore it  was  only  natural  that  he  should  behave  as  he  did.  In 
milder  cases  the  subject  is  merely  sad  and  depressed.  His 
capacity  for  work  is  diminished  but  he  does  not  react  to  his 
environment.  Doubtless  suicide  is  determined  by  these 
moods.  During  these  periods  of  moodiness  and  depression 
some  epileptics  seek  to  benumb  their  feelings  with  alcohol, 
but  bear  indulgence  in  it  very  poorly.  Much  more  rarely 
we  see  cheerful  moods  and  a  diagnosis  from  mania  is  then 
not  easy,  as  the  patients  laugh,  sing,  joke,  talk  incessantly. 
One  patient  also  exhibited  himself.  These  moods  may 
stand  in  some  relationship  with  a  seizure  but  are  also  in- 
dependent phenomena,  and  separately  described.  The 
author,  by  the  way,  claims  that  true  dipsomania  occurs 
chiefly  in  epileptics.  Aside  from  moods,  fuges,  twilight 
states,  etc.,  there  is  the  slowly  developing  alteration  of  char- 
acter. In  the  author's  experience  this  is  encountered  in 
from  90  to  95  per  cent  of  all  epileptics.  The  epileptic  as  a 
rule  does  not  lose  his  power  of  orientation  of   time,  place 

-*A.  H.  Hubner,  "  Lehrbuch.  d.  Forensischen  Psychiatrie,"  1914. 


19 

and  person.  There  is  a  slowing  of  thought,  which  seems 
to  give  rise  to  the  very  careful  circumstantial  accounts  which 
are  held  by  the  author  as  evidence  of  general  (?)  defect. 
Despite  this  carefulness  the  epileptic  does  not  express  him- 
self clearly.  The  judgment  is  always  defective  in  advanced 
cases.  Memory  fails  both  as  to  the  long  known  and  the 
new.  In  the  character  of  the  epileptic  two  qualities  domi- 
nate. One  is  the  strongly  marked  egotism  which  permits 
the  patient  to  think  only  of  himself  and  never  of  the  rights 
of  others.  The  other  is  the  inclination  to  piety,  which  plays 
a  great  role  in  the  thoughts  of  the  epileptic.  The  patient 
prays  much,  occupies  himself  with  religious  problems 
(which  he  does  not  in  the  least  understand)  and  tries  to 
convert  those  in  the  neighborhood.  They  have  God  much 
in  the  mouth,  not  often  in  the  heart.  Love  of  neighbors 
vanishes  as  soon  as  egotism  comes  to  the  fore.  The  epi- 
leptic is  a  liar,  consciously  or  unconsciously,  and  is  very 
distrustful.  He  is  rarely  cheerful,  quiet  and  approachable. 
In  the  main  he  is  easily  irritated,  gloomy  and  distrustful. 

In  accord  with  the  main  tenets  of  the  views  given  in  the 
foregoing  transcripts  one  might  cite  a  number  of  writers 
such  as  Esquirol,  Bischoff,  Clouston,  Ball,  Rtissell  Reynolds, 
Magnan,  Howden,  Romberg,  Rosenthal  and  de  Fleury. 
However,  I  think  it  may  be  considered  proven  as  far  as 
opinions  and  observations  of  the  chief  investigators  of  our 
subject  are  concerned:  ( 1 )  There  is  a  more  or  less  constant 
affective  defect  in  all  epileptics,  sane  as  well  as  insane;  that 
such  defect  is  due  to  an  inherent  make-up  of  the  psyche  in 
which  mainly  an  egoceutricity  and  a  highly  sensitized  feel- 
ing are  given  to  the  individual;  and  that  from  this 
constitutional  make-up  or  alteration  the  ultimate  deterior- 
ation of  the  psyche,  intellectually  as  well  as  emotionally, 
is  gradually  developed,  step  by  step,  and  if  the  state  is  not 
corrected  that  this  finally  and  logically  ends  in  so-called 
epileptic  dementia.  (2)  The  epileptic  alteration  is  seen  to 
proceed  from  the  mental  make-up  or  constitution  of  the  in- 
dividual epileptic  long  before  his  malady  reaches  the 
convulsive  stage  and  that  the  one  is  but  a  further  and 
final  unfoldment  of  the  former. 


20 

Lest  it  may  be  considered  unfair  to  present  only  the  pre- 
dominant and  salient  psychic  fault  as  shown  in  the  epileptic 
constitution,  I  may  mention  also  that  the  so-called  physical 
stigmata  of  the  epileptic  make-up  may  be  found  in  these  in- 
dividuals who  have  epilepsy  in  later  life.  One  must  bear 
in  mind,  however,  that  clinical  and  pathologic  studies  show 
such  somatic  defects  to  be  most  frequently  absent  in  any 
large  series  of  cases  and  that  the  physical  defects  therefore 
lose  their  etiologic  significance  in  the  after  coming  epileptic 
reactions  which  are  shown  in  seizures.  Again,  it  has  been 
urged  that  even  though  there  be  no  gross  organic  defect  in 
the  epileptic  make-up  the  general  functional  incompetency 
of  the  epileptic  economy  may  be  demonstrated.  Even 
though  this  view  be  enlarged  to  include  the  finest  methods 
of  clinico-pathologic  research  we  find  no  adequate  etio- 
logic ground  for  the  seizure  phenomena  in  a  majority 
of  all  cases  of  essential  epilepsy.  We  are  therefore  thrown 
back  again  upon  our  original  contention  that  the  fault 
in  the  constitutional  make-up  of  the  epileptic  is  psychical 
and  can  be  demonstrated  in  every  case  and  that  somatic 
defects,  when  present,  are  but  contributory  to  the  pro- 
duction of  the  fit  phenomena  in  later  life.  That  is,  the 
main  fault  in  the  psycho-biologic  defect  is  in  the  psychical 
sphere. 

I  shall  now  undertake  by  brief  citation  of  case  histories 
to  show  that  the  rudiment  of  the  epileptic  constitution  exists 
not  from  puberty,  but  from  the  earliest  childhood.  I  shall 
then  show  how  the  possessor  of  such  an  inheritance  finally 
evolves  into  the  frankly  established  epileptic  and  that  the  fit 
mechanism  becomes  a  necessary  corollary  or  sequence  of 
such  an  individual  inheritance.  I  shall  present  as  briefly  as 
possible  the  mechanism  of  attacks  in  the  paroxysmal  or  peri- 
odic cycle  of  the  disease  in  a  few  classic  cases.  In 
subsequent  papers  I  hope  to  indicate  the  immediate  and  re- 
mote therapeutic  principles  that  may  be  employed  against 
attacks  in  particular  cases,  and  finally  give  a  general  plan 
for  a  more  exact  study  of  therapeusis  for  the  disease  in 
futurd 


21 

CASE  I .  The  notes  of  the  first  case  are  those  of  a  young 
girl  of  22  years  of  age  who  has  had  grand  mal  attacks  since 
her  18th  year.  Petit  mal  have  occurred  at  varying  intervals 
of  weeks  and  months  since  she  was  16,  and  occur  with  undue 
excitement,  annoyance  or  any  excessive  stress.  She  feels 
irritated,  then  sullen  and  depressed,  and  then  "something 
bursts  through,"  and  an  attack  occurs.  The  grand  mal 
attacks  are  but  a  further  and  more  intense  elaboration  of 
the  petit  mal.  While  still  unconscious  or  confused  after  an 
attack  she  talks  baby  talk  and  acts  like  an  infant,  cooing 
and  petting  her  mother's  face  or  arm,  and  often  says: 
"  Mumsey,  I  wants  dinky."  She  then  snuggles  down  in 
bed,  often  assumes  the  fetal  position,  drawing  the  bed 
quilts  tightly  around  her  and  over  her  head.  Tongue-biting 
and  passing  urine  often  occurs  and  the  usual  symptoms  of  a 
grand  mal  attack  are  present.  She  suffers  no  apparent  in- 
tellectual impairment  and  has  produced  artistic  works  of 
considerable  promise  and  worth.  Ordinarily  she  would  pass 
current  in  society  as  a  refined  and  cultured  young  lady. 
We  shall  now  note  how  the  inherent  instincts  underwent 
development  and  what  part  they  play  in  the  attacks  above 
outlined. 

As  a  child  she  was  self-centered  and  early  had  definite  set 
views  on  just  how  things  should  be  done.  When  she  could 
not  get  her  way  she  got  square  with  the  states  of  irritation 
by  day  dreams  and  fairy  tales.  She  never  got  interested  in 
things  and  kept  at  them.  She  had  a  very  lively  temper  and 
was  not  sociable,  preferring  to  be  by  herself  in  her  dream 
world.  Life  in  a  large  city  oppressed  her  and  she  felt  fear- 
some all  the  time;  in  a  few  years  she  moved  to  a  small  town 
where  her  family  were  the  principal  society  folk  of  the  com- 
munity. She  lost  much  of  her  outward  irritability  and 
became  more  sociable,  dreamed  less  and  seemed  more  will- 
ing to  direct  her  interest  and  energies  into  better  efforts  to 

grow  up ' '  and  get  an  education.  She  began  to  have  better 
health,  there  were  less  headaches  and  she  slept  better. 
However,  the  dream  world  of  greatest  satisfaction  was  ever 
her  refuge  when  she  became  irritated  or  repressed;  she  soon 
began  to  transfer  the  useless  wonder- world  of  fairy  tales  to 


22 

that  of  poetic  composition  and  story  writing.  The  central 
themes  of  these  stories  were  mother,  childhood,  the  sea,  and 
the  dream  fancies  of  infancy.  Soon  she  grew  openly  antago- 
nistic toward  the  mother  and  her  authority.  She  could  not 
bear  to  obey  her  and  yet  in  her  fancy  she  day-dreamed  and 
wrote  of  an  ideal  and  harmonious  relationship  between 
mother  and  child.  She  says:  "  My  mother  is  English;  she 
is  very  set  and  stubborn  and  never  acknowledges  her  mis- 
takes even  though  the  argument  is  against  her."  To  meet 
this  situation  our  patient  often  selects  two  or  three  points 
that  are  in  her  favor  and  thus  ' '  saves  her  face ' '  by  such 
argumentative  subterfuge  and  she  finally  declares:  "You 
see  1  am  right  after  all."  As  regards  her  literary  work, 
which  began  in  her  12th  year  and  was  discontinued  when 
the  epilepsy  finally  broke  out,  she  says:  "  I  wrote  largely 
to  relieve  my  feelings,  bruised  and  harassed  by  an  uncon- 
genial and  unsatisfying  environment.  Then  when  the 
'  stuff '  worked  itself  up  to  a  sufficient  satisfaction,  1  got  it 
on  paper  and  felt  relieved  and  satisfied."  Then,  with  a 
show  of  keen  insight,  she  says:  "You  see  T  can't  write  any 
more  now  that  I  have  attacks;  the  attacks  let  it  all  out  of 
me  so  I  have  no  themes  or  things  worth  while  to  say." 

Just  before  the  grand  mal  attacks  came  on  she  made  an 
effort  to  sublimate  the  increasing  demands  for  expression  by 
physical  activities  but  she  was  naturally  lazy  and  sluggish 
from  childhood  and  this  effort  failed.  She  grew  more  mo- 
rose and  distrustful,  and  her  shyness  and  unsociability 
became  marked.  She  says:  "  I  began  to  see  that  the  close 
and  intimate  harmony  with  my  mother  which  I  desired  and 
which  I  tried  to  sing  of  in  my  poems  was  all  foolishness  and 
I  went  into  open  revolt  against  my  mother's  plans."  Since 
this  independent  attitude  asserted  itself  the  mother,  not 
knowing  of  the  various  internal  struggles  and  incomplete 
satisfactions  of  a  make-believe  life  which  the  daughter  had 
led,  insisted  more  fully  that  she  should  give  her  her  confidence 
and  respect.  The  daughter  could  not  do  this  and  the  frag- 
ment or  wraith  of  a  former  poetic  harmony  disappeared. 
She  then  became  definitely  outspoken  in  her  antagonism  to 
the  mother,  had  "fits  of  temper,"  sulked  and  hid  herself 


23 

from  society.  She  became  fond  of  argument  and  attached 
much  importance  to  her  position  and  views;  she  grew  pedan- 
tic and  set  in  her  ways  and  wouldn't  take  on  a  college 
training  as  the  rigid  life  of  obedience  and  acquiescence 
fatigued  and  exhausted  her.  The  irritation  increased,  she 
had  fearful  dreams,  and  headaches  came  on  daily,  except 
on  Saturdays  and  Sundays,  which  days  she  spent  as  she 
pleased.  She  could  not  adapt  herself  to  the  college  work 
and  finally  had  a  severe  grand  mal  attack  and  then  was 
quite  all  right  again  for  a  time;  but  slowly  the  old  irritation 
came  back.  There  were  days  of  annoyance  which  were 
followed  by  "blue"  periods — a  state  in  which  she  was  not 
particularly  depressed  but  in  which  she  seemed  to  suspend 
a  consciousness  of  her  environment.  She  did  not  talk,  read, 
or  do  anything,  yet  could  be  easily  aroused  from  the  lethargy. 
Usually  these  "blue"  periods  were  later  broken  by 
emotional  storms  of  temper  lasting  two  or  three  days,  or  she 
had  attacks,  after  which  the  mental  skies  were  cleared  for  a 
time.  It  may  be  said  that  just  before  the  first  grand  mal 
attack  at  college  she  had  been  very  homesick  as  well  as 
unduly  "badgered"  by  the  exacting  college  discipline  and 
that  after  the  grand  mal  attack  while  still  in  the  automatic 
state  she  fled  from  her  room  screaming  for  her  mother. 

So  often  one  hears,  on  the  one  hand,  that  epilepsy  is  a 
specie  of  feeblemindedness,  and  on  the  other,  that  many 
epileptics  of  great  ability  lack  nothing  in  the  make  up  of 
the  normal  individual.  The  following  brief  history  is  given 
of  a  man  of  36  years  of  age  who  is  one  of  the  notable 
inventive  genuises  of  our  time: 

Case  2.  Our  patient  was  born  a  delicate  child,  the 
youngest  in  a  family  of  six.  He  was  a  "crying,  difficult 
child."  He  had  teething  convulsions  during  the  first  year 
of  life.  He  was  always  keyed  up,  slept  poorly,  talked  and 
walked  in  his  sleep.  At  school  he  paid  no  attention  to  the 
studies  he  didn't  like.  In  his  own  description  he  says: 
"Literature  and  the  sciences  simply  didn't  exist  forme." 
Everything  in  regard  to  mathematics  and  the  mechanical 
world  were  attained  without  effort.     At  11  or  12  our  patient, 


24 

sensing  that  the  father  intended  to  have  him  study  his  pro- 
fession of  law,  flew  into  a  sullen  temper  and  left  home. 
He  lived  a  nomadic  life  for  three  years,  during  which 
time  he  wandered  away  into  other  countries  and  elaborated 
his  various  inventive  ideas  in  the  mechanical  field.*  A 
clever  capitalist  found  him  in  dire  poverty  in  a  foreign  city 
and  from  that  time  on  our  patient  came  into  his  own.  He 
grew  up  to  be  a  resourceful  but  "peculiar"  young  man. 
For  instance,  he  has  never  read  the  daily  papers,  has  never 
voted,  nor  taken  any  social  interest  in  the  world.  He  is 
naive  and  childlike  in  all  his  enjoyments.  Long  before  his 
epilepsy  developed  he  had  gradually  lost  all  contact  with 
the  world  of  reality  aside  from  his  particular  inventive 
sphere,  and  had  he  kept  to  this  field  exclusively  he  prob- 
ably would  not  have  developed  an  epilepsy.  But  four  years 
ago  business  conditions  required  him  to  take  an  active  part 
in  the  practical  introduction  of  one  of  his  greatest  inven- 
tions in  a  distant  city.  There  he  was  on  call  day  and  night. 
The  whole  scheme  was  on  the  point  of  falling  through,  and 
he  became  irritated  and  harassed.  Then,  too,  he  had  to 
handle  business  conferences  and  social  associations  for 
which  he  had  no  training  or  aptitude.  In  one  of  his  in- 
tensive efforts  to  manage  a  business  conference  and  while 
under  the  greatest  tension  in  explaining  his  mechanical 
apparatus  to  the  group,  the  "fatigue  state  and  irritation 
came  over  him  like  a  nausea"  and  he  had  a  momentary 
lapse  of  consciousness  in  which  he  says:  "  the  little  wave 
was  but  a  few  seconds  in  duration,  but  it  was  very  blissful 
whilefit  lasted  and  had  I  not  soon  learned  the  nature  of  the 
difficulty,  I  should  have  considered  it  as  satisfying  to  me  as 
a  short  nap."  From  this  time  on  it  was  only  a  question  of 
fatigue  and  stress,  particular  business  reverses,  or  other 
various  occasions  of  irritation,  to  bring  on  frequent  petit 
mal  or  absences  which  finally  broke  out  as  grand  mal 
attacks  two  years  ago.  Our  patient  has  had  peculiar  attacks 
of  absences  one  of  which  I  personally  witnessed.  He  was 
in  the  midst  of  a  several  hours'  intricate  exposition  of  one  of 

*It  may  be  said  that  at  present  he  has  some  fifty-six  patents,  all  practical, 
some  thirty  of  which  are  in  actual  use  and  of  great  economic  importance  and 
value 


25 

his  inventions,  when,  without  other  appearance  than  that  of 
fatigue,  he  had  three  or  four  absences  or  petit  mal  which  in  no 
wise  interrupted  his  explanation  and  following  which  he  con- 
tinued his  discourse  with  even  greater  lucidity.  I  was  looking 
directly  at  him  at  the  time  and  I  knew  of  the  "sensations " 
only  when  he  told  me  about  them  afterward.  He  said: 
"  It  was  as  though  there  were  an  instant  of  eternal  calm  in 
my  mind.  I  had  a  sense,  however,  that  I  was  automati- 
cally continuing  the  long  sentence  I  had  just  launched  and 
that  it  moved  on  by  itself;  before  it  was  finished  I  was  back 
on  the  line  of  thought  in  time  to  keep  the  full  trend  of  that 
which  was  already  started  in  the  argument  going  without  a 
break. "  Occasionally  when  our  patient  works  continually 
in  his  private  laboratory  for  four  or  five  days,  making  per- 
fect or  "fool  proof  "  some  of  his  most  intricate  mechanical 
appliances,  a  sudden  irritation  and  anger  at  the  stupidity  of 
his  assistants  comes  on  with  a  hurricane  fury  and  he  brushes 
them  all  aside  or  drives  them  outside  and  then  makes  an 
attempt  to  do  all  the  work  himself.  At  once  he  has  eight 
or  ten  sensations,  and  immediately  he  feels  calmed  and 
quieted.  He  then  becomes  patient,  kind  and  considerate, 
and  again  permits  his  workers  to  co-operate  with  him.  As 
is  not  uncommon  in  the  genius  or  creative  world,  our 
patient  dreams  a  great  deal  and  gets  many  of  his  inspira- 
tions for  new  patents  from  dreams  or  the  twilight  state  just 
after  waking.  "Awake  or  asleep,  I  am  but  in  the  different 
working  levels  of  my  inventive  mind  "  he  is  fond  of  saying. 
Again,  he  says:  "in  the  'dizzy'  turns  people  seem  to 
move  with  accelerated  speed  (sic),  and  the  people  seem  a 
bit  unreal  in  such  activity.  Of  late  the  'turns'  are  a  little 
disagreeable  inasmuch  as  they  lower  the  mental  tension 
although  they  calm  my  thoughts.  Several  times  I  have 
looked  at  myself  in  the  mirror  when  I  am  having  an  attack. 
I  appeared  perfectly  normal  to  myself,  with  the  exception  of 
once,  when  my  face  was  very  red.  I  feel  a  sense  of  elation 
and  exhilaration  when  they  come  on  and  can  feel  it  all  grad- 
ually subsiding  in  my  mind.  I  frequently  work  two  days 
without  sleep."  With  an  intensely  illumined  room  and 
plenty  of  water  to  drink  he  works  on  uninterruptedly.     When 


26 

intensely  absorbed  in  his  work  he  is  fully  oblivious  of  time 
or  surroundings.  One  may  summarize  his  character  in  that 
he  is  egotistical  and  supersensitive,  though  simple  and 
naive.  With  the  inrush  of  disturbing  reality  he  has  an  epi- 
leptic reaction.  Kept  free  from  the  latter,  under  moderate 
adjustments  of  work  he  is  free  from  attacks  of  any  sort  for 
months.  It  is  unnecessary  to  say  that  our  patient  is  extra- 
ordinarily difficult  of  control;  he  simply  "forgets"  rules 
and  regulations  of  every  sort,  and  says  "  I  must  be  allowed 
to  go  to  the  devil  in  my  own  way." 

Many  epileptics  appear  for  analysis  and  diagnosis  wherein 
it  is  not  possible  for  one  to  get  a  good  detailed  history  in  its 
finer  setting.  Again,  many  facts  are  often  lost  in  a  precise 
understanding  of  the  make-up  and  the  causes  leading  up  to 
the  epileptic  reaction.  One  must  often,  then,  be  content 
with  the  feeling  that  the  situation  might  be  made  to  yield 
much  more  than  the  surface  examination  shows  had  one  the 
whole  set  of  facts.  Not  being  solely  intent  at  this  time  in 
making  a  special  thesis  in  this  paper  I  have  selected  the  cases 
here  reported  somewhat  at  random  to  show  that  when  all  the 
data  are  not  at  hand  one  may  suspect  that  the  full  set  of  facts 
would  make  the  analysis  very  clear.  The  following  case 
was  sent  me  in  the  belief  that  it  had  none  of  the  make-up  of 
the  individual  epileptic,  nor  did  the  family  history  show  any 
of  the  psychic  taint  or  predisposition  which  would  throw 
light  on  the  occurrence  of  epilepsy  in  the  individual  patient. 
All  the  data  I  am  to  report  were  taken  in  a  single  interview 
and  given  without  leading  the  patient  or  mother  to  the  set 
of  facts  that  they  gave. 

Case  3.  The  case  is  that  of  a  boy  of  18,  who  has  had 
grand  mal  attacks  monthly  since  the  first  grand  attack  at  14. 
The  paternal  grandfather  had  a  lively,  ill-repressed  temper 
and  often  drank  to  excess;  the  father  was  nervous  and  irri- 
table, and  "  didn't  agree  with  anybody  very  often  or  long." 
He  was  called  a  "  dissatisfied  man  "  and  had  a  roving 
disposition  in  search  of  the  perfect  job.  He  drank  to  ex- 
cess, and  was  very  "difficult  "  in  the  family.  Our  patient 
and  the  father  resembled  each  other  strongly  in  physical  and 
temperamencal  make  up.     The  boy  showed  marked  prefer- 


27 

ence  to  the  mother;  he  and  the  father  were  always  at 
"  sword's  points."  Our  patient  is  the  second  in  a  family  of 
three,  the  oldest  brother  having  died  in  convulsions  at  6 
weeks.  The  infantile  and  childhood  development  of  our 
patient  was  quite  normal  except  it  was  noticed  that  he  was 
stubborn,  took  correction  badly,  could  not  be  driven,  and 
was  very  sensitive.  He  was  the  only  child  until  6  years  of 
age  and  "made  the  most  of  it."  At  school  it  was  found  he 
was  not  tactful  or  diplomatic.  While  not  quarrelsome  he 
just  walked  away,  "  threw  up  the  game  if  it  didn't  go  right." 
He  played  in  few  games  in  which  he  was  not  the  leader. 
He  was  of  a  naturally  cold  disposition.  All  his  innate  traits 
of  temperament  are  quite  the  contrary  to  those  of  his 
younger  brother.  He  became  a  day- dreamer  early  and  grew 
up  "hypersensitive  and  gloomy  like  his  father."  From 
what  may  be  imagined,  it  is  easy  to  understand  that  he  took 
his  father's  death  "  bravely."  The  father  had  many  con- 
vulsions at  his  death  from  tuberculosis,  some  two  years  ago. 
Our  patient  got  rid  of  a  good  deal  of  irritation  after  the 
father's  death  and  the  attacks  were  better  than  for  some  time 
before.  He  went  several  months  without  a  symptom.  At 
14  he  tried  to  do  work  in  a  store  and  also  keep  on  with  his 
school;  he  got  behind  in  his  studies,  lost  a  year  and  this  got 
him  very  much  irritated  with  the  store  work.  He  hated  it, 
but  stuck  to  it  until  the  nervousness  and  insomnia  caused 
him  to  walk  and  talk  in  his  sleep.  Then  he  had  a  grand 
mal  attack  at  the  end  of  a  sleep-walking  period.  He  says: 
"the  stress  of  the  work  was  too  much  for  me;  yet  I  am  con- 
tinually irritated  because  I  can  not  go  on  and  realize  my 
ambition  in  life,  and  this  seems  to  make  for  more  attacks." 
The  plan  of  treatment  in  such  a  case  is  obvious. 

Case  4  is  that  of  a  man  of  45,  who  has  had  grand  mal 
attacks  five  or  six  times  a  year  since  he  was  14.  They  be- 
gan with  petit  mal  attacks  which  are  now  of  weekly  occur- 
rence and  consist  of  "flashes  of  light  and  a  feeling  as 
though  wind  were  blowing  ever  the  entire  body."  Then 
there  occurs  a  vague  sense  of  past  scenes  and  reminiscences 
of  childhood,  and  he  becomes  unconscious.  Still  more 
recently  under  difficult  circumstances  and  harassing  diffi- 


28 

culties,  as  an  attack  came  on  in  his  sleep,  he  was  heard  to 
sigh  deeply  and  say:     "The  day  is  o'er  at  last." 

The  boyhood  setting  was  peculiar;  everything  was  done 
for  him;  even  cake  was  placed  in  a  dish  beside  his  bed  so 
that  he  might  eat  during  the  night  if  he  should  awaken 
hungry.  Finally,  the  mother  passed  her  "spoiled"  boy 
over  to  the  care  of  his  wife,  who  has  apparently  been  spoil- 
ing him  ever  since.  As  a  youth  he  learned  easily  and 
graduated  well  in  his  college  class  at  21  years.  He  had  few 
playmates  as  a  boy,  was  self-contained  and  preferred  to  stay 
at  home,  where  he  had  his  own  way.  There  were  no  par- 
ticular conflicts  called  up  until  later  life.  When  irritated 
and  annoyed  he  took  himself  to  his  music  room,  where  he 
"played  it  off  on  his  violin."  He  was  an  egotistical  and 
supersensitive  boy  and  was  handled  "with  kid  gloves"  by 
his  parents.  When  things  went  wrong  his  recourse  was  to 
his  violin  and  sombre  music.  He  was  very  stubborn  when 
crossed  and  it  is  said  that  he  underwent  quite  a  conflict  just 
before  his  first  attack,  when  he  was  finally  given  a  piece  of 
cocoanut  pie  to  quiet  him.  He  was  stubborn  and  resentful 
and  never  got  square  with  a  boy  friend  if  he  once  quarreled 
with  him.  He  was  always  over-precise  and  wanted  things 
in  their  place  and  "placed  in  a  box."  He  was  rather 
cowardly  and  given  to  self-pity  as  a  child.  He  day-dreamed 
the  most  of  his  childhood.  It  was  said  by  admiring  relatives 
that  such  states  showed  that  he  ' '  thought  deeply, ' '  little 
knowing  how  deep.  When  he  had  to  stop  the  rather  idle, 
easy  life  at  14  and  get  ready  for  college  he  could  not  take 
up  his  violin  there  and  he  found  "no  other  way  to  get 
square."  He  was  never  cheerful,  always  quiet  and  often 
taciturn.  He  craves  sympathy  and  has  never  really  gotten 
over  longing  for  his  mother,  now  dead  a  score  of  years.  At 
14.  when  irritated,  he  would  flare  up  and  then  become  sullen 
and  frequently  would  not  speak  for  days,  staying  by  himself 
in  his  own  room.  Hypersensitiveness  is  a  marked  trait  in 
the  family ;  an  older  sister  is  so  to  a  marked  degree,  and  is 
also  occasionally  epileptic  after  fits  of  extreme  anger.  The 
supersensitive  members  of  the  family  are  all  absent-minded. 
One  cousin  used  to  go  away  to  the  city  forgetting  his  wife 


29 

was  to  go  with  him  (they  are  now  separated  from  each  other). 
In  early  life  our  patient  was  abnormally  ill  at  ease  with  the 
opposite  sex.  He  had  but  one  love  affair,  at  26,  and  it  was 
reported  that  on  being  jilted  it  " nearly  killed  him."  He 
used  to  cry  all  night.  He  was  over-anxious  and  irritated 
during  the  whole  engagement.  Attacks  were  frequent  be- 
fore the  break  but  none  followed  it.  It  should  be  stated  that 
the  patient  had  great  difficulty  in  repressing  masturbatic 
habits  at  14  and  this  increased  the  inner  tension,  irritability, 
headaches,  etc.,  until  the  attacks  seemed  to  "enable  him  to 
get  square  with  the  insistent  longing  of  his  sexual  desires.1' 
As  might  be  expected,  the  possession  of  an  epileptic  con- 
stitution must  be  found  to  vary  in  degrees  in  different  in- 
dividual epileptics.  In  the  worst  adapted  individuals  the 
epilepsy  develops  pari  passu  with  the  first  impingements  of 
the  child  upon  his  environment;  in  such  one  may  find  no 
trace  of  conflict  or  struggle,  as  we  know  it  in  an  adult  sense, 
the  conflict  may  even  be  below  the  threshold  of  conscious 
life  as  shown  in  a  nameless  dread  or  a  general  irritation 
against  the  simplest  demands  of  instinctive  life.  In  such, 
one  often  sees  the  simplest  accidents  of  fright,  or  even  a 
startle  from  quiet  sleep  or  the  induction  of  a  cold  bath,  may 
cause  a  loss  of  consciousness  and  a  convulsion.  The  in- 
ternists often  designate  such  children  as  spasmophilics; 
either  congenital,  or  acquired  soon  afterbirth.  If  one  bears 
in  mind  Preyer's  elaboration  of  the  psychobiologic  conflicts 
the  healthy  infant  may  pass  through,  how  immeasurably 
greater  must  be  the  difficulty  of  those  children  handicapped 
by  poor  adaptions  to  the  stressful  life  of  the  nursling  period 
before  a  subordination  of  the  impulsive  life  of  the  child  is 
attained.  The  obverse  of  this  is  also  true.  There  are  many 
individuals  who  successfully  survive  the  perils  and  pitfalls 
of  overwhelming  conflicts  during  the  infantile  and  adoles- 
cent periods  only  to  succumb  to  conflicts  in  full  adult  life  or 
even  later.  In  such  one  needs  to  research  the  early  life 
carefully  to  determine  whether  the  epilepsy  of  later  life  is 
really  an  instance  of  essential  epilepsy  or  one  of  sympto- 
matic and  organic  origin.  It  may  be  interesting  to  show  the 
make-up  and  development  of  such  a  case  in  which  consid- 


30 

erable  doubt  was  entertained  as  to  the  essential  character  of 
the  disease  until  the  case  was  thoroughly  researched.* 

Case  5.  A  man  of  67  years  of  age,  who  was  referred  to 
me,  had  had  infrequent  attacks  of  epilepsy  since  his  43d  year. 
A  cursory  examination  revealed  no  epileptic  make-up.  The 
physical  examination  showed  our  patient  to  be  a  slenderly 
built  man,  so  well  preserved  that  he  appeared  to  be  about 
twelve  years  younger  than  he  really  was.  There  was  no 
arterial  degeneration  and  no  physical  or  functional  defects 
other  than  a  mild  degree  of  constipation,  which  followed 
some  years  after  his  epilepsy  developed,  and  at  a  time  when 
his  occupation  became  most  sedentary  in  character.  He 
has  had  an  obsessive  neurosis  of  a  classic  sort — a  fear  of 
riding  on  railroads — which  does  not  immediately  concern  us 
at  this  time.  To  research  the  make-up  more  carefully  we 
placed  the  patient  under  trained  observation  and  the  follow- 
ing facts  in  development  were  then  revealed: 

Mis  earliest  childhood  is  unknown.  It  was,  however, 
learned  that  at  school  he  found  it  moderately  difficult  to 
learn.  He  had  to  study  hard,  and  fretted  much  over  his 
studies.  His  standing  in  school  was  up  to  the  average  but 
he  kept  up  to  it  only  with  great  effort.  He  was  especially 
good  in  mathematics.  His  reports  were  signed  by  his 
mother  with  the  statement  that  she  thought  the  standing 
"was  good  for  such  a  nervous  boy."  Although  he  was 
quick  and  impulsive  as  a  boy,  very  energetic  and  under  a 
tension  most  of  the  time,  he  was  obedient  and  never  had 
tempers  or  rages.  He  was  very  sensitive  and  paid  great 
attention  to  aches  and  pains.  He  was  inclined  to  criticize 
others,  and  took  advice  and  reprimands  poorly.  He  liked 
to  form  his  own  judgments.  He  was  stubborn  and  very  set 
in  his  opinions.  He  always  had  a  tendency  to  brood,  to 
look  on  the  dark  side  of  things.  In  adolescence,  he  had 
but  one  love  affair,  which  was  broken  off  by  the  death  of  his 
fiancee.  It  took  a  long  time  for  him  to  recover  from  it  and 
even  now  he  thinks  much  of  it.  He  has  never  married. 
The  sexual  life  was  active  and  not  unusual  in  its  history. 

*In  another  paper  I  shall  undertake  to  show  how  a  patient  who  apparently 
possessed  no  epileptic  make-up,  yet  had  two  epileptic  children,  was  finally  found 
fully  to  accord  with  our  theory  of  the  disease. 


31 

In  middle  life,  several  years  before  his  epilepsy  began  and 
after  he  had  been  in  the   government  employ,  he  showed 
poor  concentration,  became  unambitious  and  lost  confidence 
in  himself.     Never  having  made  a  wide  acquaintance  in  his 
boyhood,  in  middle  life  the  anti-social  tendency  grew  upon 
him  until  he  was  almost  friendless  at  45  years  of  age.     He 
preferred  to  be  alone  at  all  times.      He  then  became  some- 
what quarrelsome  and  dictatorial  and  a  great  stickler  for 
having  his  own  way.      Me  also  began  to  grow  suspicious, 
resentful,  easily  offended,  and  held  grudges  for  along  time. 
He  soon  became  rather  jealous  and  thought  the  world  treated 
him    badly.       Dissatisfaction     with    his     occupation    and 
environment  came  on  as  he  saw  no  evidence  of  release  from 
the  governmental  position  he  occupied,  in  which  the  work 
was  exacting  and  painstaking  and  the  salary  moderate  with 
no  chance  of  advancement.     His  deeper  interests  in  political 
and  civic  affairs  began  to  dwindle  and  became  perfunctory. 
Gradually  he  became  less  frank  and  open  in  his  confidences 
with  his  business  associates.     He  kept  everything  to  him- 
self,   as    that    was   the    easiest    way.       If  confidence    was 
inspired  from  without  he  could  still  talk  freely.      He  began 
to  doubt  the  sincerity  of  all  people  and  contracted  his  own 
"never  too  strong  charitableness  and  sincerity."     Finally 
he  began   to   get   the   usual    attitude    of    old  government 
employees,  that   his  work   was   not    appreciated,  that  the 
government  was  indifferent  and  unfriendly  to  long  suffering 
servants,  and  he  talked  of  little  else  than  these  injustices. 
(  Fie  has  now  been  thirty  years  in  the  government's  employ. ) 
He  became  definitely  committed  to  a  routine  and  was  exact- 
ing about  the  way  he  did  everything,  doing  his  work  in  a 
methodical  way.      His  finicky  ways  about  personal  belong- 
ings now  spread  to  the  minutest  details  of  his  work  at  the 
office.     He  was  strong  in  his  demands  for  precision  and 
order  in  everything  and  felt  relieved  and  free  only  when  this 
feeling  was  gratified.     He  began  to  worry  and  fret  when 
this    feeling  was   not    met.     An    exaggerated  demand  for 
truthfulness  and  justice,  especially  the  latter,  began  to  grow 
upon  him.     Gradually  he  lost  the  little  iniative  he  had  pos- 
sessed and  submitted,  but  with  growing  intolerance,  to  the 


32 

"domination"  of  his  superiors.  He  then  began  to  day- 
dream and  plan  how  it  could  all  be  changed  for  the  better 
if  his  superiors  would  but  accept  his  advice,  which  they 
seemed  to  seek  less  and  less.  He  lost  courage  and  hope. 
He  became  moody  all  the  time  as  a  sort  of  protection  in 
some  way — probably  to  gain  comfort  or  respite  from  the 
growing  irritation  of  his  work  and  his  associations.  He 
then  began  to  grow  despondent  without  apparent  reason  and 
to  worry  about  his  health,  which  had  always  been  perfect 
since  a  young  bo}^.  He  finally  failed  to  make  any  effort  to 
overcome  his  despondency  and  the  fixed  mood  of  dejection 
became  more  or  less  permanent.  Soon  he  found  irritability 
and  outbursts  of  temper  were  growing  upon  him,  especially 
under  the  slightest  criticism.  He  finally  lost  interest  in  his 
work  completely,  and  at  last  lost  all  satisfaction  in  life;  he 
was  ' '  never  known  to  smile  from  one  year's  end  to  another. ' ' 
He  went  automatically  to  work  following  a  set  routine,  a 
"government  hack."  He  then  became  a  "  cog  "  in  an  in- 
tolerable government  system  which  he  detested  but  which 
he  continued  to  be  a  part  of  from  necessity.  The  re- 
pression and  depression  deepened  until  it  was  thoroughly 
intolerable,  although  he  did  not  openly  rebel.  He  kept  the 
year-long  grudges  to  himself  until  a  few  days  before  his  first 
grand  mal  attack,  when  he  was  suddenly  called  upon  to  take 
up  two  men's  work  in  mid-summer.  He  felt  he  should  die 
from  the  indignity  and  humiliation  to  which  he  could  not 
object,  and  he  had  his  first  grand  mal  attack.  In  other 
words,  he  "blew  off  the  accumulation  of  years."  Since 
then  a  periodic  discharge  slowly  accumulates  every  month 
and  he  has  repeated  grand  mal  seizures.  In  his  prolonged 
vacations  he  "feels  like  a  new  man  "  and  has  no  attacks. 

I  submit  that  the  inherent  traits  shown  in  this  man  passed 
to  their  logical  conclusion  in  an  early  psychic  deterioration 
which  occurred  long  before  his  epilepsy  broke  out,  and 
when  the  sudden  and  insistent  demand  of  irritation  stress 
was  placed  upon  such  a  deteriorated  make-up,  an  epileptic 
reaction  was  the  logical  consequence. 

Before  leaving  this  case  I  may  say  that  our  patient  was 
born  in  this  city,  of  normal  healthy  parents,  was  college- 


33 

trained  in  this  country  and  abroad;  in  business  life  at  23, 
he  went  from  one  unsuccessful  occupation  to  another  until 
the  sixth  one  finally  located  him  in  the  government  employ 
at  about  37  years  of  age,  some  six  years  before  his  first 
grand  mal  attack.  He  had,  however,  begun  to  show  the 
psychic  deterioration  sketched  several  years  before  he 
entered  the  government  service. 

Case  6.  A  further  and  more  intensive  analysis  of  the 
make-up  and  the  precipitating  psychologic  setting  in  Case 
VII  published  in  my  former  report  is  interesting  and  worthy 
of  note  here.  It  may  be  remembered  that  this  middle-aged 
man  had  the  classic  make-up  of  the  epileptic  constitution 
and  showed  the  epileptic  reaction  only  when  he  was  33  years 
old,  and  that  he  has  had  but  four  classic  grand  mal  attacks 
in  all.  He  has  now  been  for  nearly  two  years  free  from  any 
major  attacks  of  epilepsy. 

In  researching  the  dreams  after  the  last  report,  he  had 
one  as  follows:  He  was  talking  to  his  sister  at  home  about 
business  and  the  old  controversy.  She  and  he  were  very 
aggressive  but  the  patient  himself  was  the  aggressor.  He 
was  insisting  upon  his  position  and  explaining  it  in  detail. 
She  appeared  non-committal,  nevertheless  not  apparently 
believing  or  agreeing  with  him.  A  further  analysis  showed 
that  the  patient  has  a  tendency  to  "carry  things  on"  long 
after  they  have  been  settled.  He  can  not  rid  himself  of 
business  affairs  after  leaving  the  office.  Invariably  he  goes 
back  to  his  own  personal  feelings  in  reference  to  his  brother 
and  sister,  whose  attitudes,  either  in  the  dreams  or  in  the 
waking  state  always  make  him  feel  supersensitive. 

In  a  further  inquiry  about  the  gastric  neurosis,  it  seems 
that  the  first  belching  of  food  took  place  when  the  patient 
was  15  or  16.  At  that  time  his  father  had  died  and  the 
patient  was  ready  to  enter  on  his  work  of  going  into  the  firm. 
The  sister  insisted  upon  the  patient  taking  an  apprentice- 
ship in  another  business  much  against  his  inclination.  He 
disliked  the  work  intensely,  and,  in  his  words  "the  appren- 
tice business  didn't  do  him  any  good  and  it  didn't  have 
anythiug  to  do  with  the  after-work  he  should  take  up  as  a 
member  of  the  family  firm."     The  sister  said,    "  The  busi- 


34 

ness  doesn't  warrant  our  having  to  pay  you  a  salary  when 
you  are  doing  no  service  to  us,"  a  statement  which  the 
patient  has  never  been  able  to  forget. 

A  few  weeks  after  this  apprenticeship  work  was  under- 
taken he  began  to  belch  food  after  the  evening  meal.  At 
such  times  he  felt  rather  depressed,  annoyed,  irritated,  and 
the  accumulated  "  cussedness  of  the  day's  occupation  "  was 
very  nauseating  to  him.  He  could  not  express  his  views  to 
the  sister  and  this  intensified  the  heaviness  of  his  stomach 
and  the  feeling  as  though  he  wanted  to  retire  within 
himself. 

At  times  he  thought  he  really  should  submit  and  be  sym- 
pathetic to  the  family  views,  but  he  "  could  not  really  feel 
it."  There  was  a  great  deal  of  conscious  repression  with- 
holding his  very  definite  views  that  he  should  be  allowed 
to  be  independent,  but  nevertheless  as  it  had  been  decided 
upon  that  he  should  stay  at  his  work  he  kept  at  it,  day  by 
day,  always  with  the  feeling  that  he  was  doing  so  because 
he  didn't  want  to  hurt  the  feelings  of  the  family,  the  older 
sister  in  particular.  At  the  same  time  he  had  an  idea  that 
he  might  be  oversensitive  about  the  matter  and  that  it  would 
work  out  satisfactorily  in  the  end,  but  during  his  entire 
apprenticeship  he  was  never  able  to  get  his  mind  reconciled 
to  the  enforced  occupation  in  the  firm  where  he  had  been 
apprenticed. 

The  patient  admits  that  he  always  resented  correction  as 
a  boy,  especially  about  any  personal  behavior.  The  whole 
family  is  inclined  to  be  critical  and  rather  severe  upon  the 
conduct  of  the  other  members  of  the  family.  When  he  was 
corrected  as  a  child  he  usually  refused  to  comply.  Although 
he  thinks  that  the  criticism  was  unmerited  in  boyhood,  he 
felt  the  same  whether  it  was  or  was  not.  The  patient  and 
younger  sister  were  frequently  held  up  to  personal  criticism 
and  to  behavior  and  conduct  to  which  the  other  members 
of  the  family  didn't  comply.  Even  though  he  thought  the 
demands  were  just,  he  always  felt  as  though  he  didn't  get 
things  "out  of  his  system."  He  felt  a  resentment,  was 
sullen  and  irritable.  He  thinks  the  intensity  of  his  objec- 
tion to  criticism  steadily  increased  by  his  apparently  not 


35 

resenting  it  openly.  A  part  of  the  more  coercive  aspects  of 
the  criticism  disappeared  at  the  death  of  the  father.  There 
was  a  sense  as  though  his  personal  rights  had  been  trans- 
gressed and  a  part  of  it  was  also  his  natural  dislike  toward 
being  coerced  in  any  way.  He  would  carry  this  sense  of 
being  wounded  and  disliked  for  several  days.  There  always 
remained  a  "nexus  of  hurtness  and  dislike."  He  usually 
made  no  particular  effort  to  get  square  with  these  unpleas- 
ant affects  but  went  away  by  himself,  then  resorted  to 
reading  poetry  and  engaging  in  some  music.  After  such  a 
direction  of  interest  he  felt  physically  much  quieter  and  let 
down.  By  not  meeting  things  openly  he  thinks  he  produced 
a  sort  of  "subconscious  sensitiveness,"  but  in  time  he  re- 
acted openly  and  felt  relieved  by  it,  though  he  has  often 
still  felt  that  the  discharge  was  not  up  to  what  the  affect 
should  be. 

It  seemed  to  matter  little  to  the  patient  what  the  sister's 
attitude  might  be  at  the  time  of  explaining  why  she  de- 
manded a  certain  type  of  conduct.  Her  unchanged 
attitude  of  superiority  made  him  much  more  indifferent  to 
any  pleasurable  situation  she  might  initiate  in  any  social 
way. 

A  free  criticism  monologue,  of  the  doctor,  runs  as  follows: 
"Possibly  you  think  I  am  supersensitive  and  that  there  is 
an  undue  desire  for  harmony  and  sympathy,  which  is  prob- 
ably something  at  the  bottom  of  my  lack  of  real  active 
social  intercourse  and  this  in  turn  has  made  me  extra  sensi- 
tive. I  do  believe  that  1  lack  the  make-up  to  see  things  as 
they  really  are  and  you  may  think  that  I  lack  something  of 
maturity  sufficient  to  my  age — that  there  is  a  lack  of  grown- 
upness  in  my  make-up — that  you  think  I  am  not  flexible 
and  am  inexperienced;  but  I  am  not  really  lacking  in 
experience,  as  experience  would  not  necessarily  change  my 
personal  attitude;  so  long  as  my  personality  is  as  it  is,  my 
view  on  life  will  not  be  essentially  changed.  Further,  I 
look  at  things  more  sensibly  and  evenly  than  I  did, 
especially  eight  or  ten  years  ago." 

"  I  haven't  been  essentially  changed  as  regards  my  char- 
acter by  the  doctor's  impressions,  although  there  has  been 


36 

a  decided  relief  in  the  talks.  There  is  just  as  strong  a  feel- 
ing of  lack  of  sympathy  in  the  family,  and  dislike  toward 
the  sister,  as  before;  but  my  mental  emotions  are  less  buried 
now  and  find  easier  expression  and  are  more  easily  freed. 
My  general  adaptability  and  mental  agility  have  improved; 
in  other  words,  I  find  it  easier  to  relieve  my  mind.  This  is 
greatly  helped  by  my  talking  things  over  with  my  wife. 
When  I  am  free  from  the  self-consciousness,  I  am  quite  a 
different  person;  I  am  not  so  detached  from  society." 

"  I  really  think  that  the  doctor  is  not  quite  frank  and  still 
looks  on  me  as  something  of  a  child.  The  doctor  has  not 
told  me  what  he  thinks,  but  has  a  mental  reservation  as  to 
whether  my  years  are  sufficiently  full  of  experience  and  I 
think  his  attitude  is  a  slightly  derogatory  one.  I  feel  this 
at  times,  but  not  so  much  as  the  doctor  seems  to  imply. 
There  is  a  something  neglected  in  his  expression  of  what  he 
thinks  which  is  constantly  persistent.  Sometimes  it  is  more 
and  sometimes  less.  I  think  that  this  is  largely  born  of  an 
idea  of  self-superiority  and  possibly  born  of  insight  and 
knowledge.  It  may  not  be  so,  but  it  seems  evident  in  his 
manner.  I  also  think  that  the  doctor  believes  I  am  un- 
usually susceptible  to  flattery.  His  belief  is  somewhat 
analogous  to  that  which  my  sister  has.  Occasional^,  I  talk 
all  these  matters  over  with  my  wife  and  she  blocks  me  in 
expressing  them  and  says  it  is  too  deep  and  not  to  be 
talked  of." 

For  man}''  months  before  the  epilepsy  began  the  patient 
had  an  unpleasant  sleepy  feeling  about  8  p.  m.  after  dinner. 
If  the  social  situation  is  rather  interesting  the  sleepy  feeling 
is  much  curtailed  and  is  often  absent.  Oftentimes,  while 
reading  the  paper  he  feels  a  sudden  general  fatigue,  a  sort 
of  brain  fag.  His  head  feels  heavy  at  such  times,  and  there 
is  a  burning  sensation  in  the  e}^elids.  He  feels  this  sensa- 
tion much  more  when  he  is  mentally  relaxed  and  it  often 
lasts  until  he  goes  to  sleep.  When  no  one  is  at  home  dining 
with  him  he  often  sleeps  from  8.30  until  7  next  morning. 
If  he  is  allowed  to  sleep  for  two  or  three  hours  at  the  time  when 
this  lethargy  is  on  he  becomes  quite  all  right.  Ordinarily, 
the  dullness  at  this  time  contains  a  feeling  that  the  state  is 


37 

dreamless.  When  this  lethargy  is  on  he  makes  little  effort 
toward  keeping  np  bis  part  of  the  conversation,  and  he  gets 
only  snatches  of  it  as  he  arouses  himself  at  different  times. 

At  such  times  he  is  rather  irritable  and  sullen.  Some- 
times he  is  rather  ashamed  of  this  disinclination  but  he 
finally  loses  any  sense  of  shame  and  lets  himself  "drift  off" 
in  this  semi-conscious  reverie.  He  feels  then  as  if  he  goes 
off  into  space,  as  if  he  were  still  conscious  of  something 
about  him  and  knows  where  he  is  and  what  he  is  doing. 
The  whole  sensation,  however,  is  entirely  different  from 
ordinary  sleep,  "something  like  taking  ether  or  narcotics." 

Further  inquiry  shows  that  this  detacheduess  from  reality 
and  the  states  of  lethargy  are  but  heightened  states  of  sub- 
jectivity in  which  the  inner  life  dramatizes  itself,  somewhat 
like  day  dreams  and  the  states  of  mental  abstractions  which 
are  common  enough  in  those  not  epileptic;  but  that  which 
gives  them  a  distinct  pathologic  import  is  their  unmanage- 
ableness — the  slipping  away  at  times  from  conscious  control 
at  the  behest  of  something  in  him  ' '  that  demands  ' '  appease- 
ment, in  other  words  an  unconscious  demand  makes  itself 
felt  and  he  has  an  epileptic  reactive  setting  of  an  otherwise 
common  enough  everyday  abstraction  (minor  automatism). 

A  dream  in  which  the  family  conference  was  on  again  took 
place  on  another  night.  It  all  concerned  the  friendly  atti- 
tude regarding  the  former  disagreement;  previously  the 
patient  had  rather  sensed  in  the  dream  that  something  of 
an  unfriendly  situation  was  to  be  brought  up.  It  had  come 
to  a  climax  at  last  where  the  sister's  husband  was  actually 
coming  into  the  business.  Our  patient  was  outlining  con- 
ditions under  which  the  new  partner  would  enter.  Another 
"trivial  and  not  fully  remembered  dream"  was  something 
in  the  manner  of  an  explanation  being  in  progress  after  a 
sleep  which  was  begun  at  midnight  and  the  patient  awak- 
ened at  5.30  and  could  not  go  to  sleep  again.  Something 
of  the  old  fright  of  an  attack  seemed  to  be  present  in  the 
sleeplessness  that  followed,  but  there  was  something  in  the 
dream  state  not  decipherable — that  was  not  dissimilar  to 
the  old  controversy.  Later,  analysis  brought  out  that  the 
situation  was  that  of  the  old  controversy  situation  with  the 
sister,  and  her  husband  was  present  also. 


38 

Thus  one  sees  here  the  impossible  reconciliation  is  not 
allowed  to  lie  dormant  and  unsolved.  There  can  be  no  com- 
mon truce  such  as  one  usually  makes  with  the  necessity  of 
life  problem.  Undoubtedly  the  motive  that  drives  our 
patient  ever  to  seek  for  final  peace  and  harmony  is  his  ex- 
traordinary sensitiveness  and  the  nuclear  egoistic  desires 
that  no  appeasement  will  be  accepted  short  of  full  accord 
and  harmony;  for  it  would  appear  that  he  has  an  irreconcil- 
able attitude  toward  making  life  adjust  precisely  to  his  views 
and  that  while  he  may  suppress  his  inclination  to  make  his 
views  known,  yet  he  is  not  able  to  forgive,  there  is  an 
inability  to  transmute  the  hate  and  dislike  into  that  of  for- 
giveness and  love.  He  says  "this  can  not  be  done  " — that 
the  Old  Testament  concept  "rules  the  world"  and  that  he 
probably  "will  have  to  continue  with  his  disease  if  this  is 
required  before  he  can  recover."  Yet  he  admits  that  he  is 
more  flexible,  adjustable  and  is  taking  more  satisfaction  in 
life,  getting  a  larger  scope  for  his  output  of  energies,  espe- 
cially his  emotional  feelings — the  real  basis  of  treatment  in 
such  individuals. 

In  the  reversed  order  of  their  genesis,  we  have  attacks, 
a  gastric  neurosis,  supersensitiveness,  day  dreams,  abstrac- 
tions, and  essential  self-sufficiency  and  egotism.  While  the 
patient  feels  supersensitive  to  the  adaptation  which  he  re- 
quires of  other  people,  he  doesn't  permit  the  same  latitude 
of  feeling  to  others  as  regards  his  own  conduct.  He  thinks 
it  would  not  be  possible  for  him  to  take  the  initiative  in 
friendly  intercourse  with  those  of  his  own  equal  standing. 
He  is  quite  en  rapport  with  his  wife,  whom  he  recognizes  to 
have  a  diametrically  opposite  personality  as  regards  sen- 
sitiveness. Toward  no  one  else  in  the  family  or  distant 
relatives  does  he  feel  the  same,  his  grandmother  excluded; 
he  believes  she  is  absolutely  unselfish,  but  then  she  is  the 
counterpart  of  the  ideal  mother  (the  mother  imago). 

On  going  to  sleep  the  patient  frequently  "starts  all  over," 
and  occasionally  makes  irrational  statements  such  as: 
'"  What  are  you  doing?"  "  No  you  won't."  Butthe  latter 
are  frequently  made  independent  of  the  jumps  or  starts. 
There  is  a  sensation  when  the  jumps  are  made  as  though  it 


39 

immediately  sprang  from  the  epigastric  region  and  on  fully 
waking  there  is  momentarily  a  sense  of  nausea  and  disturb- 
ance of  the  proper  feeling,  which  latter  is  not  dissimilar  to 
that  which  exists  a  great  deal  of  the  time  by  day.  The  last 
six  months  there  has  been  no  "  disturbance  of  the  surround- 
ings "  or  other  peculiar  feelings  after  dinner. 

At  the  time  the  evening  sensations  or  lethargies  were  at 
their  classic  stage,  some  three  years  ago,  there  frequently 
was  present  before  the  eyes  a  bluish  tinge  in  the  air,  of  a 
Japanese  blue  tint.  This  would  last  for  two  or  three  seconds 
only,  and  often  recurred  two  or  three  times  in  a  five- 
minute  period;  a  possible  explanation  of  a  dimming  of 
consciousness  of  psychoanalytic  importance. 

The  phenomena  often  occurred  every  two  or  three  months 
in  rather  set  periods.  Often  at  these  periods  there  was  a 
desire  to  have  people  about,  not  because  they  gave  sociable 
intercourse — it  was  rather  quite  to  the  contrary — but  their 
continued  presence  would  give  the  desired  resistance 
necessary  for  him  to  exert  his  will  to  keep  a  perfect  state 
of  consciousness,  and  he  wished  to  have  them  present 
so  that  it  would  keep  away  the  fear  of  a  real  lapse  in  con- 
sciousness. Obviously,  there  were  two  kinds  of  motives 
acting,  one  perfectly  conscious,  to  retain  consciousness 
and  ordinary  mental  activity,  and  the  other,  an  unconscious 
one,  to  draw  the  patient  into  a  state  of  unreality,  away  from 
his  surroundings,  into  a  different  scene. 

Previous  to  the  sensation  the  patient  often  had  a  sort  of 
nightmare  attacks  in  which  he  thought  he  was  in  different 
surroundings,  "like  a  dream,"  out  of  which  by  an  intense 
effort  he  was  able  to  force  himself  to  full  consciousness;  as 
though  he  were  "unreal  and  dead,"  and  that  there  was  a 
struggle  to  get  back  to  reality.  After  this  there  was  a  very 
terrible  feeling,  and  blueness  came  with  it. 

All  the  phenomena  are  really  connected  at  bottom  and 
have  a  constant  point  of  departure  from  the  epigastric 
region.  The  sleep  sensations  were  as  if  one  were  fighting 
one's  way  out  of  something,  almost  indescribable.  This 
goes  with  the  blueness. 

Sometimes  in  the  past  the  ' '  mere  thought  of  it  "  brought 


J 


40 

it  on  and  most  frequently  an  effort  of  the  will  was  able  to 
drive  it  away.  There  was  always  a  sense  of  annoyance 
and  fear. 

These  "different  surroundings  "  are  almost  invariably  the 
same  in  character,  not  to  be  described,  but  as  though  the 
patient  had  been  there  before,  that  he  had  experienced  it  all 
in  a  sort  of  dream  in  which  he  was  the  center  of  the  scene, 
as  if  it  were  something  that  once  transpired  but  was  not 
consciously  remembered.  It  was  like  a  dream-state,  yet  sub- 
ject wholly  to  conscious  review.  The  agreeable  scenes  and 
happenings  in  these  unusual  surroundings  were  connected 
with  something  that  had  taken  place,  or  "  might  take  place." 
There  was  often  a  sense  as  though  people  were  about  as  in 
a  dream.  The  scene  and  visualized  sensations  were  of  the 
character  ' '  as  though  he  were  in  the  center  of  it  all,  and  all 
things  centered  about  him."  The  general  physical  sensa- 
tion was  always  unpleasant  and  distressing  when  translated 
into  conscious  terms  or  when  he  was  fully  free  from  them. 
Yet  while  there  they  were  all  pleasant  and  harmonious. 

It  is  perfectly  obvious  that  the  motive  of  the  whole 
foregoing  type  of  reaction  exquisitely  demonstrates  the 
unconscious  motivation  of  the  whole  mechanism  of  the  epi- 
leptic reaction,  namely,  the  desire  to  abolish  contact  with 
harassing  and  fatiguing  reality  and  a  desire  to  regress  to 
the  infantile  or  fetal  life  of  personal  pleasure  and  freedom. 

In  the  examination  of  our  patient's  musical  and  literary 
faculties,  we  find  that  he  is  very  fond  of  music,  dislikes  the 
modern  dancing  because  he  finds  he  is  a  bit  awkward  and 
ungraceful.  Now  that  his  violin  work  is  progressing  fairly 
satisfactorily  he  finds  keeping  his  place  on  the  score  and 
understanding  the  phrasing  melody  are  rather  difficult.  He 
is  a  little  rigid  in  his  bowing,  and  does  not  develop  the  full 
melody  in  the  harmonies  of  music.  In  tests  of  reading 
verse,  poetry,  etc.,  we  find  a  fair  attempt  toward  giving  the 
full  meaning  and  expression,  but  there  is  rigidity  in  the 
voice  and  a  certain  degree  of  improper  phrasing;  the  rhythm 
is  a  bit  jerky  and  over-emphasized.  The  poetry  in  which 
he  is  most  concerned  deals  with  the  philosophy  of  life,  its 
meaning,  tragedy,  etc. 


41 

As  regards  the  innate  feeling  of  being  irreconcilable  with 
people  who  are  radically  and  fundamentally  different  from 
him,  or  where  there  is  a  feeling  of  insincerity  in  the  attitude  a 
friend  takes,  are  all  portrayed  in  the  dreams  of  the  sister  and 
brother.  His  whole  phase  of  reasoning  and  feelings,  either 
in  the  dreams  or  in  the  conscious  state  is  quite  the  same 
now  as  when  a  child  and  has  not  undergone  any  essential 
change.  The  patient  says:  "My  brother  handles  things 
probably  better  than  I  do,  but  still  I  believe  if  he  were 
pushed  to  the  extremity  that  his  position  and  understanding 
of  things  would  be  quite  like  mine;  he  has  a  way  of  just 
letting  it  rest  without  settling  it  or  coming  to  any  final  de- 
cision or  conclusion  about  it,  while  I  seem  destined  to  be 
forever  seeking  for  a  solution  and  getting  the  matter  satisfac- 
torily ended,  and  to  gam  a  harmony  a?id  understanding  of  it. 
It  may  be,  as  you  say,  that  my  brother's  way  of  handling 
things  is  adult,  while  mine  is  still  childlike;  yet  I  believe 
mine  to  be  much  more  sincere,  and  to  be  much  the  better 
way  in  the  world." 

It  is  common  enough  to  get  dreams,  ecstatic  states  and 
delirious  episodes  in  the  epileptic  of  all  sorts  of  settings  of 
reconciliation  or  flights  from  reality,  but  the  following  rather 
beautiful  one  is  worth  giving,  in  view  of  the  previously  de- 
tailed history  of  our  patient's  firm  attachment  to  the  mother 
imago  and  the  age-long  difficulties  with  the  sister.  The 
general  setting  in  the  main  is  so  clear  that  it  is  not  neces- 
sary at  this  time  to  point  out  its  detailed  interpretation. 
The  dream  is  given  in  the  patient's  words: 

'  Last  night  I  had  a  peculiar  dream,  a  dream  in  which  a 
male  cousin  of  mine  was  sitting  at  a  table  in  a  little  way- 
side inn,  in  a  room  next  to  the  cafe,  drinking.  Very  soon 
there  appeared  a  beautiful  woman  who  danced  about  the 
table  and  sang.  No,  she  recited  blank  verse.  She  carried 
with  her  some  flowers  which  seemed  to  be  a  wreath,  and  when 
she  had  walked  about  the  table  of  my  cousin,  who  had  him- 
self joined  in  the  recitation,  she  sat  down  and  drank  with  him. 
Then  she  crowned  him  and  also  put  some  flowers  in  her  hair. 
Soon  it  was  evident,  in  this  dramatization  that  they  were  going 
through,  that  she  was  intent  upon  making  him  drunk,  and  as 


42 

the  boisterousness  increased  with  more  intoxication  she  led 
him  to  propose  to  her,  which  he  did.  Then  suddenly  it  seems 
as  though  the  wedding-  festivities  had  taken  place  and  they 
started  hand  in  hand  down  the  road,  still  reciting  the  blank 
verse  in  dialogue.  The  roadway  was  decorated  with  trees, 
shrubbery  and  blossoms,  the  sky  was  blue,  and  the  whole 
setting  was  that  of  a  beautiful  spring  day.  Suddenly  across 
the  roadway  a  fence  was  interposed,  which  barred  their  way. 
Into  this  fence  a  square  hole  was  cut,  about  the  size  of  a 
big  window.  While  still  reciting  the  blank  verse  and  act- 
ing (although  it  seemed  like  real  life),  they  leaned  through 
this  window  and  seemed  on  the  point  of  falling  through. 
Suddenly  the  fence  disappeared,  and  in  the  next  setting  of 
the  dream  the  woman  seemed  to  have  fallen  in  the  roadway 
and  received  a  mortal  wound.  My  cousin  stooped  and  held 
the  woman's  head  and  wiped  away  the  dirt  and  blood  stains 
from  her  face.  She  was  still  reciting  to  him,  but  the  theme 
was  now  changed  to  a  long,  full  rhythmic  metre  and  it 
seemed  as  though  she  were  about  to  die,  and  was  asking  his 
forgiveness  for  all  the  wrongs  she  had  inflicted  upon  him 
and  the  things  she  had  induced  him  to  undertake  for  her 
sake.  Then  she  sang,  or  rather  spoke,  of  Burgnovia;  it 
seemed  to  be  a  sort  of  Altruia,  where  eyerything  was 
peaceful  and  serene,  heavenlike;  a  place  of  perfect  peace, 
contentment  and  satisfaction. 

"To  all  this  the  man  replied,  in  blank  verse  without 
rhythm,  of  forgiveness;  and  while  she  was  reciting  this 
ecstatic  poem  I  felt  thrilled,  and  as  though  it  were  some- 
thing which  I  had  once  known  myself  but  had  forgotten, 
and  I  began  to  recite  with  her  the  exalted  words  in  the  poem 
dialogue.  Just  then,  at  the  height  of  the  ecstasy  of  the 
words  which  thrilled  me  intensely,  she  arose  from  the  road- 
way, and  the  play  dramatization  was  at  an  end.  I 
awakened  with  a  start;  I  felt  thrilled  and  ecstatic  and  abso- 
lutely sleepless  the  remainder  of  the  night.  It  was  3  A.  M. 
when  I  awoke  and  I  remained  wide  awake;  I  was  blissfully 
happy  and  contented  all  the  day  and  could  still  repeat  the 
theme  in  the  dream,  which  was  still  ringing  in  my  ears. 
Otherwise,  during  the  day  everything  was  the  same  as  usual, 
and  I  felt  quite  well." 


43 

Thus  we  have  a  reconciliation  with  the  sister  and  some- 
thing deeper,  plus  the  "heavenly  flight"  from  all  the 
"earthly  sorrows." 

Relative  to  the  first  grand  mal  attack  that  the  patient  had 
six  months  after  marriage,  there  were  many  situations  of 
adjustment  at  the  time  of  getting  married  which  disturbed 
him  considerably.  After  about  two  months  of  marriage  a 
trip  to  Europe  was  proposed,  largely  at  the  instigation  of 
his  wife,  in  which  plans  our  patient  acquiesced  and  he  pre- 
pared to  arrange  for  the  trip,  although  at  the  time  he  was 
still  somewhat  perturbed  over  the  older  conflicts  with  the 
brother  and  sister,  particularly  the  sister. 

As  the  time  drew  nearer  for  the  sailing,  the  patient  felt  an 
increasing  feeling  of  tension  and  a  sort  of  nameless  dread 
and  fear  took  possession  of  his  mind  most  of  the  waking 
period.  This  fear  was  not  in  reference  to  crossing  the  ocean, 
but  the  possibility  of  illness  of  his  wife  or  himself  while 
abroad.  He  had  ' '  inwardly  a  very  strong  desire  not  to  go, ' ' 
but  the  preparations  went  on  from  day  to  day  and  he  began 
to  feel  under  greater  tension  and  inward  disapproval  of  the 
whole  project.  While  he  had  made  his  adjustment  to  his 
wife's  manner  of  living  and  thought  and  feelings,  he  thought 
that  she  had  not  quite  adjusted  to  him. 

He  remembers  no  similar  fears  except  when  he  was  a 
child,  and  this  brings  up  the  old  associations  as  a  child;  the 
sister  had  a  tendency  to  make  light  of  such  latent  fear  rather 
than  treating  the  matter  by  a  simple  process  of  talking  it 
out.  The  ' '  mother-  attitude  ' '  was  lacking  in  this  as  in  other 
situations  previously  outlined  bv  the  patient. 

The  night  before  he  was  ready  to  sail  he  felt  restless  and 
ill  at  ease,  depressed,  with  a  certain  aspect  of  forebodings 
and  also  of  annoyance  that  his  wife  failed  to  comprehend 
the  real  reasons  why  he  didn't  look  with  more  favor  on  the 
trip.  The  suggestion  had  been  hers  and  it  seemed  as  though 
she  had  not  quite  caught  his  views,  about  what  might  be 
worrying  him.  Had  he  taken  the  time,  as  he  says,  to  ex- 
plain to  her,  undoubtedly  she  would  have  appreciated  his 
position  and  probably  modified  plans  to  suit  him.  In  the 
patient's  words,  "the  anticipation  was  as  great  as  actual 


44 

realization,  and  with  this  idea  in  mind  I  went  to  sleep.  I 
felt  rather  ashamed  that  I  was  so  hypersensitive  about  it 
and  so  little  able  to  get  the  mastery  of  myself."  During 
this  night  he  had  his  first  grand  mal  attack. 

When  the  patient  was  asked  in  what  relationship  he  saw 
the  foregoing  in  relation  to  the  attack,  he  said:  "The 
attack  was  an  evasion  of  my  mind  from  going  on  the  trip." 

To  any  one  who  has  followed  the  inherent  epileptic  types 
of  defects  of  instincts  and  their  gradual  unfoldment  into 
the  adult  character,  the  gradual  formation  of  day-dreaming, 
mental  abstractions,  lethargies  and  dream  episodes,  the 
"starts"  and  partial  dimmings  of  consciousness,  all  of 
which  are  motivated  by  the  same  unconscious  forces,  one 
may  wonder  where  the  epilepsy  really  began.  If  one  de- 
sires to  mark  its  advent  by  the  occurrence  of  definite  seizure 
phenomena,  then  it  is  clear  when  our  patient  contracted  his 
disorder.  But  if  one  takes  the  view  of  the  newer  clinical  re- 
searches, one  finds  that  such  an  epileptic  as  outlined  here 
has  always  had  epileptic  reactions  and  will  probably  always 
continue  to  have  them  in  some  form.  Obviously,  the  defi- 
nite episodes  of  petit  mal  and  grand  mal  can  be  fully 
eliminated  if  the  psychobiologic  habits  of  life  are  properly 
adjusted  and  the  environmental  stress  does  not  suddenly  be- 
come too  severe  and  demanding.  The  mystery  of  frequent 
relapses  in  the  epilepsies  becomes  no  mystery  if  one  views 
such  cases  in  their  broader  aspects. 


45 


Section  II. 

A  STUDY  OF  THE  EPILEPTIC  MAKE-UP,  THE  MECHANISM  OF 

THE  FIRST  ATTACK,  AND  SOME  OF  THE  MORE  NOTABLE 

LIFE  REACTIONS  OF  AN  EPILEPTIC. 

One  is  apt  to  forget  that  the  psyche  is  undergoing  de- 
velopment pari  passu  with  the  physique  as  a  whole,  and 
can  therefore  see  no  general  application  of  the  adult  formu- 
lation that  the  epileptic  reaction  is  a  more  or  less  direct 
outcome  of  the  epileptic's  inability  to  stand  the  stress  and 
harassments  of  life  from  which  he  seeks  automatic  or  un- 
conscious withdrawal.  In  a  former  essay*  I  undertook  to 
explain  how  the  two  principles  were  to  be  reconciled.  One 
should  not  think  of  the  childish  conflicts  on  the  same  level 
as  the  adult  ones,  but  no  one  may  doubt  that  at  their  par- 
ticular level  they  are  as  keen  and  painful  as  any  adult 
experiences.  Common  experience  proves  this  to  be  true. 
Not  infrequently  a  denial  of  this  truth  has  led  one  to  think 
that  the  child  and  primitive  peoples  are  entirely  free  from 
the  ordinary  trials  of  existence,  hence  the  assumption  that 
nervous  disorders  in  children  occur  on  some  exogenous  or 
physical  basis  rather  than  on  a  psychogenic  one.  The  more 
recent  studies  of  the  psychopathies  of  children  prove  that 
the  numerous  disorders  of  childhood  have  their  origin,  not 
upon  a  full  adult  elaboration  of  a  complicated  psychic  pro- 
cess, but  upon  the  plane  of  inhibition  and  control  of  the 
impulsive,  instinctive,  reflex  and  ideational  life  of  the  child 
or  infant.  Therefore  we  might  expect  that  the  epochs  of 
new  adaptations  entailing  new  and  more  elaborated  forms 
of  stress  would  be  the  periods  of  life  in  which  we  would 
find  the  most  frequent  epilepsies  to  occur.     We  find  that 

*"  Study  of  Certain  Aspects  of  Epilepsy  Compared  with  the  Emotional  Life 
and  Impulsive  Movements  of  the  Infant,"  Interstate  Medical  Journal,  Vol.  22, 
No.  10,  October,  1915. 


46 

two-thirds  of  all  the  epilepsies  begin  under  twenty  years  of 
age.  Indeed,  it  has  often  been  stated  that  epileptic  attacks 
occurring  after  twenty-five  years  of  age  are  to  be  looked 
upon  askance,  as  not  being  of  idiopathic  origin.  While  of 
course  one  knows  this  is  not  literally  true,  yet  the  fact  that 
the  great  majority  begin  in  earliest  life  makes  one  hesitate 
to  ascribe  the  essential  disorder  to  any  other  cause  than  an 
error  in  the  developmental  life.  This  being  granted,  one 
may  note  that  the  period  from  birth  to  two  years  is  the 
great  one  to  which  the  infant  finds  the  impulsive  and  auto- 
matic processes  of  life  must  be  adapted.  The  second  stress- 
period  of  marked  objectivation  of  the  individual  child 
takes  place  at  beginning  to  talk  and  to  walk.  The  third  is 
that  of  the  school  or  community  adaptations  at  five  to  eight 
years.  The  fourth  comes  at  puberty,  which  is  the  stressful 
period  of  physiologic  and  psychologic  separating  of  the 
individual  from  the  home  ties.  This  period  is  the  one  par 
excellence  for  the  beginning  of  epileptic  reactions  in  psy- 
chopathically  endowed  children.  The  enormous  demand 
of  social  adaptations  in  work  and  the  marriage  relations 
from  puberty  to  adulthood  makes  us  understand  why  so 
large  a  number  of  epilepsies  develop  at  this  time. 

Perhaps  the  issue  is  most  difficult  of  acceptance  in  the 
infantile  period,  hence  a  few  remarks  regarding  this  period 
will  not  be  out  of  place.  In  the  development  of  mind,  in 
its  simplest  beginnings,  we  note  that  the  actual  or  potential 
epileptic  child  shows  bad  adaptive  tendencies  even  in  the 
first  adjustment  called  for.  For  instance,  sucking,  biting 
and  chewing  are  often  imperfectly  performed.  Such  in- 
fants nurse  at  irregular  intervals,  they  bite  and  chew  their 
food  with  gormandizing  habits,  they  slobber  and  drool, 
and  bolt  their  food  in  immoderate  boluses.  There  is  often 
a  lack  of  rhythm  and  smoothness  in  movements  of  the 
tongue  and  hands.  Such  children  are  often  incoordinate 
and  slow  in  learning  to  sit,  creep,  stand  and  walk.  The 
jumping  and  climbing  movements  are  awkward  and  lacking 
in  elasticity.  The  reflex  movements  are  over  excitable, 
especially  in  regard  to  light,  sound  and  contact.  They  are 
easily  startled.     The  instinctive  life  shown  in  disposition 


47 

is  without  quietude  and  is  filled  with  unrest  in  tone  or 
feeling.  The  extra  lability  of  mood  is  shown  in  the  mean- 
ingless fits  of  crying  and  laughing.  Finally  the  delibera- 
tive life  is  motivated  by  reasons  whimsical  and  lambent, 
which  disturbs  the  proper  development  of  judgment  and 
will.  Similar  defects  may  be  seen  in  simple  psychopathies  of 
childhood,  but  the  peculiar  grouping  of  them  around  the 
strong  individualism  and  supersensitiveness  of  the  epileptic 
make-up  give  them,  when  thus  constellated,  the  peculiar  dis- 
tinctions of  the  nucleus  of  the  after-developing  full-fledged 
character  of  the  classic  epileptic.  So  soon  as  this  stubborn 
and  intensive  individualism  comes  in  contact  with  an  un- 
yielding environment,  like  spun  glass  without  elasticity,  it 
breaks  into  tantrums  and  rages,  crying  spells  of  impotence, 
and  finally  into  epileptic  attacks  of  a  definite  character. 
The  breadth  of  contact  with  the  environment  is  narrowed, 
the  child  soon  loses  the  advantages  of  physical  development, 
and  emotional  and  intellectual  retardation  begins.  The 
speech  and  emotional  expression  become  stiff  and  woodenish, 
even  though  more  intense  defects  may  or  may  not  appear. 
If  such  defects  of  the  instincts  are  not  molded  to  normal 
principles  of  development  the  individual  child,  not  being 
able  or  willing  to  adapt,  steadily  makes  larger  and  larger 
demands  on  its  environment,  and  when  this  adjustment 
is  not  forthcoming,  the  break  occurs.  Not  infrequently 
a  sense  of  heightened  subjective  feeling  comes  with 
an  extraordinary  supersensitiveness  of  the  senses;  thus  one 
of  my  little  patients  has  learned  to  care  only  for  people 
whose  touch  she  likes,  and  although  but  nine  years  of  age, 
for  several  years  past  she  has  unconsciously  classified  her 
acquaintances  by  the  kind  and  quality  of  handshake  or 
kiss.  Another  designates  his  friends  by  their  individual 
odors  (like  a  dog).  It  is  easy  to  comprehend  how  a  dull 
and  inelastic  world  must  disturb  such  barometric  sensitive- 
ness. How  prosaic  and  stupid  the  ordinary  sensate  world 
appear  to  the  supersensitive  epileptic,  and  with  what 
satisfaction  he  must  dream  of  another  world,  where  all  was 
supplied  without  even  a  wish  or  command.  There  is  little 
wonder  that  the  epileptic  imaginings  and  day-dreams  are 


48 

so  vivid  and  real  that  reality  is  easily  cast  off  in  frequent 
lapses  of  consciousness.  It  is  also  easy  to  understand  that 
with  such  a  casual  desire  to  maintain  the  proper  mental 
tension  of  interest  such  an  individual  may  quickly  deteri- 
orate in  mind  and  body,  and  that  he  carries  in  his  innate 
personality  the  forces  for  frequent  severance  of  contact  with 
reality  until  the  relationship,  as  MacCurdy  has  excellently 
shown,  may  be  more  or  less  allowed  to  lapse  into  what 
seems  to  the  casual  observer  to  be  an  inconsequential  neg- 
lect. A  complete  life  study  of  a  youthful  epileptic,  with 
the,  foregoing  in  mind,  is  instructive.  When  one  under- 
stands such  a  case  in  its  extreme  bearings  upon  origin, 
prognosis  and  treatment  of  the  disorder,  the  latter  holds  less 
of  strangeness  and  mystery  and,  above  all,  it  clearly  points 
the  way  for  further  study  of  such  families  en  bloc  to  estimate 
correctly  the  importance  and  magnitude  of  the  modern 
problem  of  eugenics. 

In  order  to  estimate  properly  the  innate  defects  of  in- 
stincts which  our  patient  possesses  and  which  will  be  de- 
tailed later,  it  is  desirable  that  we  briefly  review  the  make- 
up of  the  family  stock.  The  father  was  an  extremely  re- 
sourceful business  man.  His  early  life  was  spent  in  a  home 
where  extreme  strictness  of  discipline  was  maintained. 
His  brothers  and  sisters  left  home  early  and  avoided  much  of 
the  early  exactions  of  the  parents,  but  the  father  of  our 
patient  early  learned  to  repress  his  own  views  at  home 
and  elsewhere,  and  grew  up  largely  a  stranger  to  his  friends 
and  business  associates.  He  never  belonged  to  a  firm,  but 
always  carried  out  his  business  operations  alone  and  un- 
aided. Outwardly  he  gave  little  evidence  of  egotism  or 
conceit,  but  "deep  down  inside"  (a  favorite  expression  of 
relatives  in  giving  the  real  character  make-up)  he  had  such 
definite  and  positive  views  that  he  was  never  known  to  be 
persuaded  to  accept  any  others.  His  charities  and  benevo- 
lences were  of  a  perfunctory  sort,  but  he  saw  to  it  that  his 
contributions  were  larger  and  more  apparent  than  those  of 
anyone  else.  He  had  the  implacable  hate  of  an  "Indian," 
and  was  never  known  to  forgive  an  injury.  .  He  was  extra- 
ordinarily supersensitive,  yet  covered  it  up  by  retracting 


49 

into  himself  or  by  a  studied  aloofness.  He  adapted  illy  to 
new  environments.  Wherever  he  went  he  must  have  the 
same  rooms,  food  and  service  year  after  year.  This  rigid  and 
definite  attitude  was  marked  even  in  early  manhood.  His 
wife  became  easily  disciplined  to  his  manner  of  living,  and 
seemed  to  have  personally  contributed  to  his  rigid  attitude 
toward  life  until  he  had  the  home  and  environmental  set- 
tings of  an  "  Oriental  potentate."  At  the  time  of  his  mar- 
riage at  48,  his  first  and  only  love  attachment,  he  had  built 
such  a  wall  of  reserve  about  him  that  "hardly  anyone 
penetrated  it."  His  attitude  toward  the  realities  of  life  was 
practical  and  matter-of-fact.  He  took  all  things  seriously 
and  quietly.  Never  by  word  or  sign  did  he  show  that  re- 
verses affected  him.  He  never  showed  that  he  cared  for 
sympathy  or  affection.  In  a  large  business  panic — eleven 
out  of  thirteen  banks  in  his  native  city  failed  at  one  time, — 
he  underwent  a  stressful  financial  period  for  three  or  four 
years,  but  he  never  mentioned  his  difficulties  to  anyone 
except  in  "  a  laconic  sentence  or  two"  to  his  wife.  Later 
in  life  (62  to  65)  he  displayed  some  tempers  from  which  he 
recovered  slowly.  He  never  used  tobacco  or  alcohol,  never 
went  to  public  amusements  of  any  sort,  and  considered  time 
thus  spent  as  a  sheer  waste.  All  his  life  habits  were  equally 
set  and  formed,  everything  even  to  the  exact  folding  of  a 
newspaper  was  according  to  a  system.  It  was  a  crime  for 
him  or  his  family  to  be  a  second  late,  and  he  insisted  that 
the  whole  household  live  on  the  same  schedule  as  he  had 
planned  for  himself.  His  religious  views  were  those  of  an 
"extremely  conservative  Catholic,"  and  he  despised  all 
modernisms.  For  years  he  had  sick  headaches  and  "  dizzy 
turns,"  but  they  gradually  ceased  before  his  death  at  68 
from  arteriosclerosis. 

One  may  ask,  why  did  not  a  man  with  such  an  extra- 
ordinarily rigid  character  have  "genuine"  attacks  of 
epilepsy?  The  answer  may  be  made  that  while  he  had  a 
narrow  contact  with  reality,  it  was  intense,  self-generated, 
and  had  continued  variations  of  appeal  such  as  a  varied 
business  career  ordinarily  affords. 

Inquiry  into  the  make-up  of  the  mother's  family  shows  that 


50 

there,  too,  is  somewhat  the  same  type  of  inheritance.  The 
grandfather  (84  years  of  age)  is  a  strong,  austere  man,  un- 
yielding and  domineering,  and  "rules  everything  in  sight." 
The  whole  family — the  mother  of  our  patient  included — 
have  great  conceit  and  pride.  All  the  women  of  the  family 
rule  their  husbands  and  have  to  be  at  the  head  of  any  club, 
organization,  or  social  affair  in  which  they^enter.  They  are 
rigid,  precise  and  definite  in  all  their  views  and  purposes. 
Added  to  this  egotistical  make-up  they  all  have  violent  tem- 
pers and  "never  forgive  or  forget."  The  mother  says  of 
herself,  "  I  used  to  have  a  violent  temper  myself,  with  tan- 
trums and  rages,  but  at  my  marriage  at  27  years  of  age  I 
learned  to  get  square  with  it  by  the  training  my  husband  gave 
me,  which,  I  suppose,  I  would  not  have  taken  or  heeded 
from  anyone  else.  After  marriage  I  never  flew  into  a  rage 
as  before.  Under  my  husband's  supervision  I  improved  all 
the  time.  I  suppose  I  didn't  have  epileptic  attacks  as  a 
consequence  of  the  suppression  of  incipient  rages  because 
I  didn't  have  time  for  them,  and  besides,  the  rapid  appear- 
ance of  a  large  family  of  children  made  life  varied  and 
interesting.  Yet  I  did  get  headaches  and  exhausted  feel- 
ings when  the  rages  were  imminent.  But  after  a  time  they 
all  disappeared,  and  I  became  a  healthy,  happy  mother  to 
my  six  children.  Even  now  though,  I  find  the  old  rages 
are  deep  down;  they  are  rarely  provoked  sufficiently  to  rise 
to  the  surface — and  besides,  I  haven't  got  time  to  work 
them  up."  From  this  statement  one  may  infer  the  mother 
has  practically  corrected  in  her  make-up  the  potentiality  for 
epileptic  reactions  by  a  varied,  earnest  and  continuous  out- 
flow of  spontaneous  interest.  She  has  thus  objectivated  her 
intense  individualistic  desires — a  consummation  devoutly  to 
be  wished  for  in  all  epileptics,  but  which  is  so  infrequently 
fully  attained. 

The  eldest  son  of  the  foregoing  union  is  our  patient,  a 
young  man  of  22  years  of  age  who  has  had  typical  grand 
mal  attacks  from  his  17th  year.  The  epileptic  disorder  began 
with  sensations,  and  myoclonoid  ' '  jerks ' '  or  spasmodic 
twitchings  accompanying  such  "sensations."  The  latter 
symptoms  still   persist  in  the  mornings  before  rising  and 


51 

occasionally  recur  during  the  day.  It  may  be  stated  at  the 
outset  that  our  patient  suffers  from  no  physical  disability 
whatever.  He  has  been  repeatedly  examined  by  experi- 
enced internists  and  specialists  and  no  physical  disorder  has 
ever  been  found  that  could  in  anyway  be  even  remotely  con- 
nected with  the  causation  or  continuance  of  his  epilepsy. 
His  birth  was  a  rather  difficult  first  pregnancy  (five  un- 
eventful ones  have  occurred  since) .  The  father  was  50  and 
the  mother  28  years  old  at  our  patient's  birth.  He  was  a 
bottle-fed  baby  and  cried  all  the  time  for  the  first  three 
months.  Teething  was  difficult  and  began  only  after  he 
was  a  year  old.  He  was  a  fat  baby  and  much  constipated. 
Although  he  did  not  cry  ' '  very  much ' '  after  the  first  six 
months,  he  was  still  restless  in  conduct  and  behavior,  and 
very  stubborn  and  demanding.  He  began  to  talk  at  18 
months  and  made  progress  slowly  and  with  difficulty;  later, 
at  7  to  9  years,  he  began  to  stammer,  and  had  "speech 
cramps  "  when  excited,  irritated  or  thwarted  in  his  plans  or 
desires.  He  was  not  a  physically  strong  child,  and 
appears  to  have  had  "latent"  rickets  and  wore  ankle 
braces  for  the  first  few  months  of  learning  to  walk.  He 
was  a  ' '  dainty ' '  eater,  finicky  and  precise  in  little 
ways  and  made  adjustments  slowly  to  the  ordinary- 
nursery  ethics  of  the  home.  He  was  slow  and  "  difficult  " 
in  the  kindergarten.  Partly  on  account  of  the  foregoing 
and  partly  on  account  of  his  stammering,  which  steadily  in- 
creased in  spite  of  special  training  to  remove  it,  he  failed  to 
get  the  regular  school  training.  His  power  of  concentra- 
tion was  but  fair,  and  he  was  slow  in  "getting  down  to  his 
work."  He  had  an  aversion  to  most  studies;  they  did  not 
really  interest  him  and  he  quickly  learned  to  day-dream  a 
good  deal,  which  habit  in  its  elaborated  form  will  be  dealt 
with  again  in  a  more  adult  setting.  He  observed  well  in 
some  things  but  he  often  took  notice  of  things  in  an  odd 
way,  e.  g.,  he  often  noted  the  stripes  and  colors  of  paint  on 
road  and  field  carts,  but  could  not  remember  who  was  in 
them  or  how  many  there  were.  Having  little  interest  in 
things  of  an  abstract  nature,  he  turned  his  interest  to  the 
concrete  and  mechanical.     About  this  time  (8  or  10  years) 


52 

it  was  noticed  he  did  not  make  a  good  friendly  contact  with 
his  playmates.  He  became  exacting-  and  insistent  that  his 
standards  alone  should  be  followed.  He  was  quick  and  im- 
pulsive, yet  planned  well  and  had  a  definite  purpose,  and 
used  tools  well  as  everything  mechanical  pleased  him.  He 
was  active  and  lively  as  a  child  and  always  wanted  to  build 
things,  but  in  doing  so  they  must  be  "just  so."  He  was 
egotistical  yet  very  sensitive  "deep  down  inside."  These 
two  faculties  made  him  rather  shy  and  reserved  with  stran- 
gers. It  was  said  of  him:  "  If  he  had  an  opinion  and  you 
another,  his  must  prevail.  He  never  forgave  or  forgot  a 
a  real  injury.  He  was  never  tactful,  but  on  the  other  hand 
he  did  not  go  out  of  his  way  to  quarrel.  If  he  thought  you 
were  doing  wrong  he  would  let  you  know  about  it  in  no  un- 
certain terms."  While  he  was  obedient  as  a  small  boy  it 
was  always  evident  that  he  wanted  his  own  way,  and  would 
try  to  get  it  sooner  or  later.  Though  critical  in  natural  tem- 
perament, he  would  take  advice  well,  or  "at  least  listen 
respectfully."  He  was  easily  offended  and  had  many  jeal- 
ous moments  in  adjusting  himself  to  the  new  situations  of  an 
after-coming  family  of  brothers  and  sisters.  He  was  not  es- 
pecially frank,  and  never  demonstrative.  His  reactions  to 
daily  affairs  were  for  the  most  part  on  the  surface  and  gave 
one  no  clue  that  there  were  deep  currents  of  unrest  and  dis- 
satisfaction. He  has  always  been  committed  to  a  routine. 
His  belongings  must  always  be  just  so  in  his  room;  this  insist- 
ence upon  preciseness  was  innate  and  had  much  to  do  with 
his  slowness  and  indecision.  While  not  inclined  to  take  the 
lead  he  did  not  care  to  be  led.  He  was  always  fantastic,  and 
his  air-castle  building  of  what  he  wanted  to  do  in  life  was 
much  beyond  his  innate  capacity  of  realization,  and  did  not 
show  a  very  keen  insight.  His  mood  was  always  one  of 
underlying  seriousness.  He  was  not  enthusiastic  but  rather 
pessimistic  and  very  conservative  in  his  innate  tendencies. 
His  great  ambition  at  the  present  time  is  to  run  his  mother's 
extensive  farm  before  the  superintendents  in  charge  break 
it  down.  He  is  quite  perfunctory  in  his  religious  ideas;  he 
does  not  see  that  his  attitude  of  not  forgiving  an  injury  is 
essentially  unchristian,  and  easily  assumes  a  stern  literal 


53 

moralistic  attitude  toward  the  shortcomings  of  the  workmen 
on  the  farm. 

One  may  picture  the  actual  facts  of  his  youthful  career 
by  saying  that  when  he  stopped  at  home  he  did  somewhat 
as  he  pleased  and  got  on  fairly  well;  when  he  went  to  pri- 
vate schools,  usually  secular,  he  had  his  main  difficulties. 
His  difficulties  at  one  of  these  schools  are  shown  in  the 
following  statement  of  the  patient: 

"While  in  this  school  my  speech  got  worse;  the  professor 
and  another  who  had  charge  of  us  in  the  yard  and  during 
the  time  we  were  not  in  classes  threatened  to  mop  the  floor 
with  me.  I  was  about  15  years  old.  There  were  a  couple 
of  other  boys  as  old  as  17  and  they  were  afraid  of  them  and 
would  give  in  to  these  two  men.  They  used  to  beat  the 
kids,  and  me  too.  They  would  use  a  stick  or  a  strap  and 
were  always  threatening  us.  All  the  teachers  did  it  more  or 
less,  but  these  two  in  particular  had  the  devil  in  them.  I 
used  to  get  the  worst  of  it.  If  we  didn't  stand  in  line  just 
right  they  would  get  cranky.  They  would  hit  us  on  the 
hand  and  probably  at  night  when  we  were  in  bed  the}r  would 
come  after  us  then." 

It  is  comparatively  easy,  then,  to  understand  that  with 
the  demanding  exactions  of  this  school  life  the  patient  re- 
acted with  extreme  nervousness,  did  poorly  in  his  class  work 
and  lost  ground  physically.  In  the  interim  between  the 
school  periods,  he  spent  his  summer  vacations  in  the  free 
open  life  at  the  seashore,  horsebacking,  swimming,  etc.,  and 
in  the  evenings  attended  dances  and  little  social  affairs  and 
theatre  entertainments.  In  his  words:  "I  liked  this  life 
very  much."  In  short,  without  stress  and  necessary 
demands  our  patient  got  on  quite  all  right. 

We  find  that  he  was  subject  to  masturbation,  as  early  as 
10  years  of  age  and  he  remembers  having  discussed  such 
acts  with  the  boys  at  8  to  9  years  of  age.  At  11  it  was  tem- 
porarily stopped  and  he  apparently  got  square  with  the 
physical  restlessness  induced  thereby  by  physical  gymnas- 
tics, coasting,  and  Nature  study.  But  at  16  the  habit 
returned  and  he  was  involved  in  it  for  six  months.  He 
kept  it  up  until  January  or  February  in  the  year  preceding 
his  first  grand  mal  attack. 


54 

We  may  now  take  a  view  of  the  mechanism  of  the  onset 
of  the  attack:  First  we  have  the  instinctive  defect  as 
already  outlined;  this  entailed  an  inadequate  development, 
retarded  his  intellectual  processes  and  rendered  him  inade- 
quate to  meet  the  school  training  (probably  not  of  the  best) 
but  which  many  another  boy  stood  and  "got  away"  with. 
His  precocious  sexuality  at  puberty  ran  an  irregular  and 
prolonged  course  and  he  failed  to  make  the  next  adaptation 
in  adolescence  required  of  the  normal  boy.  He  could  not 
sublimate  the  defective  puberty  habits  into  an  objective  life 
of  work  and  play  and  sympathetic  outside  interests.  Re- 
garding his  school  life  he  says:  "You  see  I  am  naturally 
slow  and  deliberate  and  I  think  I  was  sort  of  paced  off  my 
feet.  Of  course,  I  didn't  study  or  work  harder  than  any 
number  of  other  boys,  but  I  just  simply  could  not  do  as  they 
did  and  get  away  with  it." 

When  asked  what  happens  at  the  slight  sensations  he 
says:  ' '  The  loss  of  consciousness  is  much  like  taking  ether 
or  chloroform.  I  seem  detached  and  slowly  sinking  out  of 
life.  Things  seem  far  off  and  I  am  removed  from  life;  not 
dead,  but  just  suspended,  away  from  things."  Thus  one 
sees  he  is  involuntarily  withdrawn  from  reality,  which 
happens  to  coincide  with  the  motive  of  his  conscious  desire. 

Thus  the  motivation  of  the  first  series  of  ' '  sensations ' ' 
and  attacks  would  seem  to  have. been  brought  about,  in  part 
at  least,  by  certain  types  of  pleasurable  acts  that  are  com- 
monly employed  for  "  outraged  nerves "  as  seen  in  many 
another  neurotic.  Further,  the  patient  says:  "After  the 
severe  attack  if  they  put  something  cold  on  my  head  it 
seemed  to  soothe  me,  and  in  point  of  fact  when  I  was  a 
child  stroking  my  head  by  someone  whose  hands  were  cold 
often  put  me  to  sleep  and  lessened  my  headache,  and  has 
apparently  often  prevented  my  attacks." 

Regarding  his  attacks  of  anger  and  general  irritability, 
he  says:  "When  I  get  angry  to  a  moderate  degree  I  walk 
away  from  the  difficulty,  but  if  it  grows  serious  I  burst  out 
in  a  torrent  of  words;  I  see  red,  I  fight  and  I  never  am  really 
able  to  forget  or  forgive  an  injury." 

Regarding  his  habit  of  day-dreaming  and  its  use,  vicari- 


55 

ous  or  otherwise,  as  a  help  to  ward  off  attacks  or  to  get 
square  with  a  too  demanding  environment,  our  patient  says: 
"  I  think  from  the  period  beginning  with  the  stress  in  school, 
and  more  frequently  thereafter,  I  day-dreamed  a  great  deal. 
When  things  went  badly  I  used  to  day-dream  more.  Just 
preceding  the  day-dreams  and  castle-building  I  would  be  a 
little  depressed  and  the  day-dreams  seemed  to  help  me  out 
of  it." 

Again,  in  further  elaboration  of  the  cause  of  the  disorder 
of  flights  away  from  reality  (loss  of  consciousness)  and  the 
desire  for  acts  of  pleasurable  liberation  of  a  crude  sort  our 
patient  states:  "  You  see,  my  physical  coordination  is  slow; 
I  never  drew  well  nor  did  any  mechanical  thing  easily,  and 
when  I  am  hurried  up  or  the  work  is  more  exacting  it  often 
drives  me  into  a  sort  of  muscular  cramp,  particularly  in 
my  speech.  I  felt  in  school  as  if  I  were  over- pushed  and 
when  I  came  home  I  wanted  some  fun,  some  other  kind  of 
energy  in  me  needed  to  be  released.  You  see  I  had  an  hour's 
lesson  of  speech  work  and  then  I  went  bicycling,  but  I  had 
to  bicycle  very  fast  to  cover  the  distance  to  get  -to  the  gym- 
nasium and  back;  neither  the  gymnasium  work  nor  the 
cycling  was  real  fun;  they  were  too  forced  and  it  was  too 
much  in  the  nature  of  a  drilling  for  me  to  take  it  leisurely 
or  get  as  much  fun  out  of  it  as  I  would  have  had  had  I 
played  handball  and  free  sports." 

Many  patients  have  a  vague  sense  of  the  direction  in 
which  they  must  proceed  in  order  to  get  well,  as  shown  in 
our  patient's  remarks,  "I  can  get  well  by  doing  the  op- 
posite of  what  I  did  in  getting  sick,  and  I  want  sleep  and 
lots  of  it,  and  then  I  seem  to  want  a  sober,  nice  lot  of  fun 
and  I  think  in  that  way  I  will  be  able  to  release  this  deep 
down  energy  which  doesn't  find  a  proper  outlet  in  any  of 
the  things  that  I  have  been  accustomed  to  doing." 

To  show  that  the  stammering  is  a  part  of  the  same  mech- 
anism as  the  epilepsy,  we  note  the  patient's  statement,  "My 
stammering  and  inability  to  speak  gradually  came  on  at 
six  or  seven  years  and  was  worse  every  time  I  put  prohi- 
bitions against  free  pleasures,  play,  and  finally  self-abuse, 
and  whenever  difficult  tasks  were  to  be  met,  like  reciting, 


56 

talking  over  the  telephone  or  meeting  people  (defense 
mechanism  and  prohibition).  When  I  am  not  tired  and  not 
obliged  to  hurry  and  can  take  my  own  leisure  I  have  little 
or  no  stammering." 

For  a  short  period  before  the  disease  developed  and  ever 
since  that  time  there  has  been  a  sudden  wave-like  fluctua- 
tion of  three  to  four  weeks  of  feeling  quite  all  right  and 
three  to  four  weeks  in  which  the  patient  is  nervous,  a  little 
irritable,  slightly  depressed,  and  the  stammering  is  much 
more  intense.  These  depressions  in  general  feelings  and 
general  fitness  succeed  a  number  of  different  causative  fac- 
tors, such  as  lack  of  sleep,  too  much  excitement,  over  in- 
dulgence in  food,  and  depressing  emotions  and  exhilarations 
due  to  too  much  social  activity. 

Very  frequently  during  the  depressed  periods  there  occur 
slight  mental  abstractions  during  which  the  patient  persists 
in  the  activities  previously  indulged  in  and  during  which 
he  is  unable  to  undertake  any  new  alteration  of  the  same 
(slightest  grade  of  diminished  activity  of  consciousness 
short  of  an  attack).  During  the  nervous  and  depressed 
periods  our  patient  conserves  his  energies  by  sleeping  longer 
in  the  morning,  engages  in  such  mild  occupations  as  going 
to  the  post  office,  doing  simple  errands,  seeing  a  few  family 
friends  or  lying  about  reading  light  literature  that  requires 
no  special  effort.  If  sudden  intensive  and  stressful  work  is 
called  for,  or  great  adaptations  to  a  new  environment  is  re- 
quired, he  is  apt  to  have  a  severe  grand  mal  attack.  He 
has  always  disliked  the  city  and  liked  the  freer  life  of  the 
country  where  he  can  take  things  easy  and  do  things  that 
he  has  an  inclination  to  do.  He  would  now  enjoy  going  to 
the  city  for  a  day  or  two  and  ' '  speeding  it  up, ' '  and  then 
would  like  to  return  for  a  comfortable  rest  in  the  country, — 
the  basic  principle  in  many  a  "periodic' ' 

Another  attempt  at  elucidating  the  motive  producing  the 
epileptic  disorder  shows  that  the  mildest  sensations  began  in 
August  or  September  of  1910.  It  seemed  they  were  brought 
about  by  an  inability  to  get  rid  of  the  "energy"  and,  on  mak- 
ing an  attempt,  to  force  sleep;  when  this  state  of  mental  ex- 
hilaration was  on,  thoughts  of  a  rather  exciting  character, 


57 

which  had  formerly  been  of  a  sexual  nature,  were  now  di- 
rected toward  driving'  automobiles,  sailing  ships,  riding  the 
bicycle,  etc.  Such  thoughts  were  not  satisfying  and  in- 
creased the  tension,  and  when  these  thoughts  were  turned 
away  from  and  sleep  did  not  supervene  the  feelings  of  a 
"sensation"  occurred.  In  a  still  more  frankly  autobio- 
graphical statement  he  said,  "  If  I  had  had  someone  to  do 
things  with  me  I  would  have  been  able  to  liberate  thL  energy. 
When  I  knew  that  I  had  to  go  to  sleep  the  concentration  of 
my  mind  on  the  necessity  for  sleep  would  bring  on  the  sen- 
sations. These  sensations  were,  and  still  are,  the  fore- 
runners of  the  same  kind  of  things  that  lie  at  the  bottom  of 
my  severe  attacks.  There  was  a  sensation  in  the  head  as 
though  it  was  shaking  inside,  a  vibration;  it  was  slightly 
unpleasant  as  it  interrupted  the  ordinary  train  of  thought 
and  yet  it  gave  relief  and  I  could  then  go  to  sleep." 

Again,  "I  tried  to  make  the  exhilarating  thoughts  of 
ordinary  physical  activity  succeed  the  sexual  thoughts 
completely  about  in  May.  I  had  succeeded  in  getting 
square  with  the  former  in  greater  part  during  the  winter  and 
they  dissappeared  entirely  in  May  or  June."  Then  in  July 
and  August  all  sexual  ideas  were  completely  changed  into 
strivings  for  physical  activity,  dancing,  swimming,  etc. 
But  these  did  not  give  full  freedom  to  the  pent-up  energy, 
and  additional  efforts  towards  forcing  the  mind  to  change 
from  these  to  that  of  a  mental  concentration  on  going  to 
sleep  was  sufficient  to  break  the  mental  states  into  attacks. 
He  says,  "  It  was  as  though  I  had  a  certain  kind  of  a  job 
to  do  in  order  to  go  to  sleep.  After  a  time  the  sensations 
seemed  to  be  caused  from  a  loss  of  sleep  and  then  concen- 
tration of  the  will  made  them  more  frequent  and  severe — 
the  sensation  and  the  loss  of  sleep  made  the  necessity  for 
sleep  all  the  more  important,  but  the  sensations  seemed  to 
make  sleep  a  little  more  easy  to  attain;  they  let  off  the  extra 
tension."  Similar  reasoning  is  given  in  the  not  infrequent 
use  of  alcohol  when  one  is  extra  fatigued  and  can  not  get  to 
sleep.  The  same  principle  is  shown  in  the  whining  cry  of 
infants  who  are  too  excited  or  fatigued  to  go  to  sleep  until 
they  have  had  their  crying  spell. 


58 

He  continues,  ' '  I  am  persuaded  that  the  sensations  and 
the  disease  really  all  began  in  my  mind  and  the  difficulty 
of  controlling  the  same,  and  making  it  become  satisfied 
with  things  as  they  really  were,  especially  in  the  ability  to 
change  my  train  of  thought  from  the  unsatisfying  physical 
activities  to  that  of  going  to  sleep.  In  September  the  sen- 
sations came  fast  and  severe  when  I  was  really  starting  in 
at  very  hard  school  work  and  when  there  was  no  pleasure 
to  keep  my  mind  in  an  active  state,  or  even  half  way  satis- 
fied, such  as  had  been  the  case  during  the  summer.  I  felt 
all  in.  If  there  was  an  accumulated  fatigue  the  sensations 
would  come  up  on  trying  to  go  to  sleep." 

Since  coming  under  trained  observation  and  treatment 
(a  period  of  ten  months)  our  patient  has  had  but  two  grand 
mal  attacks,  although  his  daily  average  dose  of  45  grains 
of  bromides  has  been  entirely  removed.  The  patient  seems 
to  have  been  able  to  drive  all  conscious  thoughts  of  sexual- 
ity as  such  out  of  his  mind,  but  as  usually  happens  in  such 
direct  repressions  when  the  former  are  not  digested  or  sub- 
limated, the  dreams  are  filled  with  sexual  matters,  most 
frequently  of  the  simplest  and  crudest  sort,  and  occasion- 
ally with  those  of  a  thinly  disguised  symbolical  character. 
Such  dreams  occurred  almost  nightly  for  the  first  month. 
As  time  progressed,  however,  they  became  less  frequent 
and  insistent  until  now  (end  of  ten  months)  they  are  from 
a  week  to  two  weeks  apart.  He  says,  "A  nocturnal  emis- 
sion makes  me  feel  the  next  morning  as  bad  as  though  I 
had  had  an  actual  attack,  yet  the  dreams  (nocturnal  emis- 
sions) seem  to  provoke  an  attack;  they  seem  to  stir  some- 
thing in  my  mind,  deep  down  that  must  come  out  or  up." 
We  know  the  nocturnal  emissions  or  even  masturbation 
often  serves  as  an  inciter  to  normal  desire  for  coitus.  Prob- 
ably the  lack  of  a  conscious  psychic  discharge  in  such 
dreams  or  masturbatic  acts  creates  a  real  need  for  the  latter. 
Still  more  likely,  the  dream  was  but  the  organic  demand 
not  gotten  square  with  in  the  daily  sublimations.  In  some 
measure  the  sensations  and  attacks  in  this  case  are  defin- 
itely related  to  this  unrequited  psychic  discharge  teased  up 
by   nocturnal   emissions.      However,   most  frequently  the 


59 

causes  for  individual  attacks,  now  seen  in  our  patient,  are 
endogenous.  For  instance,  abreacting  from  a  painful  sit- 
uation, that  of  a  fellow  patient's  death,  our  patient  had 
been  much  concerned  to  find  that  his  companion  could  not 
be  recovered  from  his  fatal  pneumonia;  he  became  some- 
what depressed,  day-dreamed,  was  listless  in  his  usual 
sports  and  duties  and  finally  had  a  grand  attack,  and  while 
confused  in  the  state  subsequent  to  the  convulsion  (auto- 
matic state)  he  went  to  his  own  bed  and  lifting  the  cover- 
let he  corkscrewed  his  way  under  the  bedclothes  until  he 
reached  the  foot;  after  getting  a  little  breathing  space  he 
drew  all  the  clothes  snugly  over  his  head  and  body  and 
with  a  rhythmic  petting  and  rocking  of  the  body  he  then 
went  to  sleep.  But  just  before  he  fell  asleep  he  was  heard 
to  mutter,  "Everybody  is  all  right  now;  Mr.  A.  is  well, 
isn't  he?" 

I  would  consider  the  above  to  be  an  abreaction  from  a 
too  painful  situation  and  an  infantile  flight  to  the  protection 
and  comfort  of  a  state  of  metroerotism.  Although  he  went 
about  much  relieved  after  this  attack,  on  learning  his  friend 
was  not  better  but  considerably  worse  he  was  again  de- 
pressed; as  he  said,  "it  is  still  in  my  system  and  not  out 
yet." 

In  order  that  he  might  receive  the  benefits  of  vocal  cul- 
ture for  stammering  he  was  given  lessons  for  two  or  three 
months.  We  find  singing  defects  in  our  patient  analogous  to 
those  noted  previously  in  other  epileptics  (Clark  sign),  a  gross 
defect  in  the  general  emotional  life.  His  teacher  reports 
that  he  had  a  very  defective  faculty  of  appreciation  of  notes 
by  the  ear,  and  was  not  able  to  sing  the  scale  when  he  be- 
gan his  work,  but  after  some  practice  he  is  now  able  to  strike 
octaves  on  the  key  with  few  exceptions.  The  melody  and 
harmony  qualities  of  the  voice  are  bad.  The  tones  are  not 
well  sustained  and  the  phrasing  is  still  very  incoordinate. 

To  show  how  slight  and  trivial  the  external  cause  may  be 
in  inducing  attacks  in  such  an  individual,  it  was  noticed 
at  first  that  whenever  attention  was  forced,  especially  to 
giving  attention  to  conversation  or  explanations  where  the 
subject  was  a  difficult  one  to  follow,  the  patient  often  felt  a 


6o 

sort  of  aching  pain  that  arose  from  the  back  of  his  head 
and  came  to  the  front,  and  this  endured  for  a  period  of  eight 
or  ten  seconds.  During  this  time  patient  said  he  was 
half  conscious,  felt  rather  absent-minded  but  was  able  to 
repeat  what  was  actually  going  on;  he  was  unable  to  hold 
his  mind  on  the  subject,  and  would  not  be  able  at  such 
times  to  reply  in  an  intelligent  manner.  This  was  particu- 
larly so  when  he  started  on  a  subject  which  someone  was 
reading  to  him,  or  when  he  was  greatly  fatigued.  The  sen- 
sation came  from  the  back  of  the  head  and  projected  for- 
ward to  the  right  eye  and  sometimes  to  the  left.  As  the 
sensations  gradually  disappeared  these  states  of  mind, 
which  were  a  sort  of  warning  of  lighter  phases  of  what 
would  have  been  sensations,  seemed  to  take  their  place. 

After  three  months  of  special  treatment  it  was  noted  that 
our  patient  fussed  less  about  his  room,  his  habits  were  more 
orderly,  direct  and  definite,  he  did  better  work,  was  more 
persevering,  less  irritable  and  made  excellent  progress  in 
his  reading  and  discussion  of  ordinary  events  of  everyday 
life.  The  sensations  were  much  less  frequent,  many  times 
only  to  be  recognized  by  the  patient  himself.  The  myo- 
clonic jerks  were  seen  only  at  times,  as  noted  in  the  notes 
that  follow.  There  was  a  steady  decrease  in  childish  traits 
and  manner  of  conduct;  coordination  was  better;  the  speech, 
except  on  occasions  when  he  was  under  considerable  ex- 
citement, was  very  nearly  normal.  In  the  dreams  his  gen- 
eral attitude  was  much  less  openly  sexual  in  character,  the 
nervous  periods  were  less  intense  and  less  resistant.  As 
regards  the  day-dreaming,  on  the  tennis  court  it  was  fre- 
quently noticed  that  he  would  be  fairly  talkative,  would 
stop  his  work,  and  stammer  badly.  Very  frequently  his 
ideas  became  so  vivid  to  him  that  he  stopped  working  and 
stared  in  front  of  him  or  looked  listlessly  in  the  opposite 
direction  and  it  seemed  as  though  he  was  having  a  petit 
mal  attack.  Careful  analysis  showed  that  this  was  but  a 
form  of  day-dreaming  in  which  he  was  carrying  out  some 
elaborate  fancy  about  what  he  intended  to  do  when  he  got 
home. 

The  simple  use  the  patient  makes  of  dreams  of  attacks  is 


61 

given  in  the  following  instance:  In  the  night  he  had 
dreamed  that  he  had  had  an  attack  and  that  when  he  awak- 
ened next  morning  he  wanted  to  go  down  to  his  breakfast 
but  the  nurse  would  not  let  him,  saying  that  he  would  bring 
his  breakfast  up  to  him.  The  patient  thought  this  dream 
was  real,  as  his  nurse  was  dressed  and  out  of  the  room  when 
patient  awakened  in  the  morning. 

Under  precise  daily  analysis  and  observation  we  find  that 
our  patient  begins  the  day  by  dressing  according  to  a  defi- 
nite routine  which  is  invariably  followed.  When  this 
routine  is  interfered  with  he  becomes  sullen  and  uncom- 
municative and  finally  if  not  released  from  it,  he  flies  into 
abusive  rages.  His  greatest  wish,  which  lies  at  the  bottom  of 
his  day-dreams,  is  to  return  home  and  assume  his  position 
as  head  of  the  family;  to  enlarge  the  ranch,  and  to  make  suf- 
ficient money  so  that  he  would  not  have  to  borrow  from 
anyone;  he  wants  motor  cars,  a  launch  and  a  private  fishing 
and  hunting  preserve.  He  never  expresses  a  wish  that  does 
not  center  about  himself.  While  to  ordinary  observation  he 
appears  to  be  gentlemanly,  kindly  and  courteous,  he  can 
easily  be  aroused  at  the  fancied  aggressive  qualities  which 
he  believes  his  companions  entertain  towards  himself  and 
others.  In  all  his  daily  activities  he  continually  strives 
to  reach  a  state  of  perfection  for  purely  personal  sat- 
isfaction and  pleasure.  No  subject  is  too  monotonous  for 
him  to  argue  about.  His  set,  rigid  views  frequently  throw 
him  into  violent  conflict  with  everyone  about  him,  and  not 
being  able  to  shift  or  modify  his  opinions  the  consciousness 
of  getting  the  worst  of  the  argument  causes  him  extreme 
annoyance.  Avoiding  all  discussion  is  the  one  way  to 
obviate  disappointments. 

An  episode  in  the  life  of  our  patient  is  worth  citation  for 
several  reasons:  First,  because  one  may  see  the  manner  in 
which  a  sentimental  attachment  may  harmfully  excite 
deeper  sexual  desires,  and  inflate  other  unconscious  de- 
sires, withdrawing  the  libido  from  safer  and  more  stable 
sublimation,  and  provoking  epileptic  symptoms  in  conse- 
quence. Secondly,  the  situation  gets  beyond  all  the  ordinary 
character  controls,  and  at  the  height  of  the  condition  char- 


62 

acteristic  sexual  dreams  appear;  these  being  unsatisfying, 
the  tension  is  relieved  by  desultory  employment  and  sport. 
Then  there  follows  a  renunciatory  dream  of  more  intensity, 
after  which  the  unconscious  demands  begin  to  collapse,  and 
the  patient  is  finally  saved  from  an  attack. 

Our  patient  had  been  introduced  to  a  young  lady  for 
whom  he  gradually  formed  ideas  of  an  attachment  of  a  more 
or  less  sensuous  character.  He  talked  and  walked  with  her 
and  engaged  in  some  athletic  sports.  So  soon  as  the  attach- 
ment, more  or  less  clandestinely  planned  for,  had  advanced, 
he  dropped  off  his  study  and  work  in  shop  and  garden.  He 
became  restless,  snappy  in  his  conversations  and  disinclined 
to  follow  any  routine.  He  spent  long  times  in  his  room 
alone,  could  not  concentrate  his  attention,  and  everything 
went  wrong.  He  felt  "tired  all  over."  Long  talks  with  a 
fellow  patient  followed  on  sexual  matters  and  marriage. 
He  then  began  to  have  frightening  dreams  of  robbers,  fire, 
etc.,  and  others  of  a  frankly  sexual  character.  He  had 
rather  persistent  headache,  did  no  work  and  could  not  sit 
or  lie  still.  His  sensations  (petit  mal)  then  began  to  appear. 
He  could  not  converse  with  anyone,  and  stammered  greatly. 
Going  about  doing  as  he  wished  seemed  the  only  way  he 
could  "avoid  having  a  grand  mal  attack."  He  finally  be- 
gan to  complain  of  various  aches  and  pains,  fussed  with  his 
clothes  and  bureau  drawers.  He  moved  about  slowly,  rub- 
bing his  head  and  face  and  grunting  to  himself.  The 
sensations  then  increased  to  mild  "myoclonoid"  jerks  but 
they  were  not  sufficient  to  throw  him  down.  He  now  took 
nearly  two  hours  to  dress  in  the  mornings,  was  dull,  grouchy, 
and  answered  briefly  or  not  at  all  at  the  table.  He  could 
not  decide  in  anything  and  was  reduced  to  complete  phys- 
ical and  mental  impotence.  He  still  carried  on  a  lively 
imaginative  fancy  in  regard  to  the  girl,  although  he  no 
longer  saw  her  or  wrote  to  her.  He  said  afterwards  that  he 
was  "in  a  fog  or  a  mist,"  had  felt  nervous  all  over,  and 
wanted  no  one  to  speak  in  his  presence.  He  no  longer  had 
any  particular  aversion  to  anyone  about  him  or  to  any  phase 
of  his  environment;  he  simply  wanted  peace  and  quiet — to  lie 
abed  and  neither  sleep  nor  dream  (extreme  shrinking  from 


63 

reality).  He  then  had  a  dream  of  conquest  and  triumph, 
which  ended  in  a  magnificent  renunciation.  Following 
the  '  great  "  dream  he  felt  less  shut  out  of  reality  and  in  a 
couple  of  days  gradually  came  back  to  his  study,  work  and 
play.  During  the  greater  part  of  this  episode,  as  he  was 
not  able  to  ascertain  the  real  nature  of  his  conflict  our  pa- 
tient was  allowed  to  do  just  as  he  pleased;  he  was  "let 
alone"  by  the  others  and  gradually  succeeded  in  "righting 
ship"  without  having  a  grand  mal  attack. 

As  an  illustration  of  the  difficulties  the  patient  has  ex- 
perienced in  adapting  to  a  new  environment,  the  following 
gives  us  an  understanding  of  many  of  his  personal  char- 
acteristics not  yet  fully  adjusted  or  subdued: 

He  displayed  no  particular  interest  in  the  departure  from 
the  country  at  the  end  of  the  summer  season,  other  than  the 
usual  preparations  of  packing,  etc.,  in  which  he  showed  the 
childish  attitude  of  being  unable  to  decide  what  should  be 
done  first,  becoming  depressed,  annoyed  and  upset  when  he 
was  not  allowed  his  way.  He  was  quite  satisfied  to  return 
to  the  suburbs  and  pleased  with  the  arrangements  that  were 
being  made  about  his  accommodations,  for  this  had  all  been 
explained  to  him  and  he  knew  what  to  expect. 

On  arriving  at  the  new  quarters  he  looked  over  both 
houses  and  at  once  decided  to  live  in  the  house  Miss  X. 
occupied.  This  house  appealed  to  him,  and  by  being  lo- 
cated there  he  saw  an  opportunity  of  being  relieved  of  the 
necessity  of  associating  with  a  Mr.  A.  for  whom  he  enter- 
tained a  great  dislike.  It  may  be  said  that  this  dislike 
started  quite  naturally;  when  he  first  joined  the  club  some 
ten  months  ago  he  became  very  fond  of  the  companionship 
of  a  certain  girl  patient  and  her  nurse,  but  on  the  arrival  of 
Mr.  A.,  who  was  more  developed,  quick  and  naturally  clever, 
he  was  gradually  crowded  out  of  this  girl  and  nurse  asso- 
ciation. Jealousy  and  envy  of  Mr.  A.  then  grew  apace. 
Now,  when  he  was  informed  that  it  was  not  feasible  to  take 
accommodations  in  this  house,  he  sulked,  became  grouchy, 
and  went  about  the  house  frowning  and  mumbling  to  him- 
self and  otherwise  showing  his  displeasure.  He  answered 
only  when  absolutely  necessary,  and  then  only  in  monosyl- 


64 

lables.  Explanations  by  the  nurse  and  physician  relieved 
the  tension  somewhat,  at  least  to  the  extent  of  making  it 
more  bearable,  but  it  was  evident  that  it  still  held  a  promi- 
nent place  in  his  mind.  When  he  was  told  that  he  must  not 
hold  grudges,  and  that  he  only  made  himself  unhappy  by 
assuming  this  antagonistic  attitude,  he  said:  "  If  I  give  in 
now  it  will  only  be  worse  next  time." 

Finding  he  could  not  gain  his  point  in  regard  to  having 
his  room  changed,  he  turned  his  attention  to  getting  permis- 
sion to  spend  a  whole  day  in  the  city.  He  was  informed  by 
his  physician  that  half  a  day  would  suffice  to  attend  to  his 
business  there.  This  produced  the  grouchy  condition  again, 
and  he  went  about  with  sullen  expression,  mumbling  to  him- 
self and  otherwise  appearing  displeased  at  not  being  able  to 
have  his  own  way.  He  said  he  was  being  treated  like  a 
boy.  The  grouch,  however,  gradually  passed  off,  and  he 
became  cheerful  with  everyone  and  at  once  turned  his 
attention  to  golf,  wood  carving  and  his  correspondence 
course. 

However,  such  a  prolonged  degree  of  stress  and  irritation 
had  at  last  to  be  repressed,  and  two  or  three  days  after  he 
began  to  develop  a  period  of  extra  frequent  and  severe  my- 
oclonoid  jerks  for  several  mornings.  In  the  language  of  his 
nurse:  "He  came  within  an  ace  of  having  a  grand  mal 
attack." 

As  is  well  known,  each  frankly  established  epileptic  has 
a  more  or  less  definite  cycle  of  recurrence  of  attacks.  In 
this  case  the  distance  between  the  crest  of  the  wave  of  one 
incipient  storm  to  the  other  has  gradually  widened  from  a 
few  days  to  several  weeks.  The  intensity  of  each  rising 
storm  period  steadily  lessens.  For  instance,  we  have  a  day 
or  two  of  irritability  when  things  go  altogether  badly,  inter- 
est in  all  work  and  play  falls  away,  and  there  succeed 
several  days  of  dilapidation  finally  ending  in  a  period  of 
rest  and  extra  sleep;  then  once  more  our  patient  begins  to 
mend  his  desultory  interest  and  start  in  again  on  his  corre- 
spondence course,  handicrafts  and  outdoor  sports.  He  is 
then  contented,  free  from  "sensations"  and  any  stress. 
He  soon  desires  from  pride  or  ambition  to  hurry  the  previ- 


65 

ously  neglected  duties  faster  than  he  is  able  rightfully  to 
manage;  then  there  soon  succeeds  a  feeling  of  increased 
nervous  tension,  some  defect  in  concentration  and  attention 
and  a  failing  grasp  and  retention  of  the  subject  matter. 
This  irritates  and  disheartens  the  patient.  He  then  lays  the 
discouragement  upon  some  trivial  misunderstanding  with 
his  associates,  which  finally  ends  in  arguments  and  dis- 
agreements. Stammering,  slowness  and  awkwardness  in 
all  duties  again  come  to  the  fore,  and  our  patient  is  again 
at  the  crest  of  another  break.  Even  though  the  bad  hand- 
ling of  his  activities  is  so  obvious,  to  gain  his  confidence 
and  acquiescence  to  guidance  is  no  easy  matter.  That  he 
has  had  no  grand  mal  attacks  in  a  year,  however,  speaks 
well  for  the  routine  handling  of  such  a  case. 

Finally  I  may  say  that  the  myoclonoid  jerks  have  largely 
disappeared,  under  ordinary  circumstances.  For  the  most 
part  they  have  been  concentrated  into  morning  ' '  sensations  ' ' 
and  are  appreciable  only  to  the  patient.  He  has  become  in 
a  large  measure  well  adapted  to  his  particular  environment, 
attends  to  his  gardens,  engages  in  wood  carving,  and  stud- 
ies well  with  little  prompting.  He  is  much  less  restless, 
irritable  and  self-  assertive,  and  is  thoroughly  interested  in 
the  whole  system  of  physical  and  mental  upbuilding. 

We  may  briefly  summarize  this  case  by  saying  our  young 
man  had  certain  inherent  traits  and  instincts  from  birth, 
and  as  his  general  development  advanced,  these  defects  be- 
came more  telling  factors  in  hindering  the  development  of 
proper  intellectual  and  moral  habits.  These  in  turn  re- 
tarded and  weakened  the  whole  capacity  of  the  young  man 
to  adjust  himself  to  adolescent  life;  the  friction  of  the  en- 
vironment became  too  great,  and  he  could  not  make  the 
sublimation  of  the  masturbatic  period  into  sports,  play,  and 
finally  work  of  adult  life.  It  would  seem  when  the  mastur- 
batic habits  had  to  be  repressed  the  lack  of  an  adult 
adaptation  or  outlet  increased  the  tension  to  the  point  that 
the  unconscious  demands  chose  nothing  less  than  a  com- 
plete epileptic  reaction  by  withdrawing  the  individual 
entirely  from  a  too  demanding  environment  (in  loss  of  con- 
sciousness);   later,   when    this    failed   to  be  sufficient,   the 


66 

degree  and  amount  of  release  demanded  superadded  con- 
vulsive phenomena,  as  indicated  in  my  former  studies. 
Undoubtedly  the  neurotic  symptoms  of  stammering  in  this 
case  were  a  partial  and  earlier  break  into  a  neurosis  at  a 
higher  level;  this  mechanism  of  defense,  on  the  part  of  the 
organism  unfortunately,  and  yet  like  most  other  neurotic 
symptoms,  entailed  further  and  severer  handicaps  on  our 
patient  and  made  the  wreckage  of  a  final  epilepsy  more  com- 
plete. The  crying  demand  for  an  early  and  wise  therapeusis 
in  such  cases  is  only  too  obvious. 

Lest  one  may  think  that  too  much  stress  is  laid  upon  the 
definite  psychologic  settings  in  the  causation  and  continu- 
ance of  the  epilepsy  here,  it  may  be  said  that  there  are 
also  physical  counterparts  to  the  maldevelopment.  If  not 
shown  in  actual  physical  anomalies  they  can  still  be  shown 
in  functional  incompetence.  To  meet  these,  such  as  the 
defect  in  vasomotor  tone,  hydrotherapy  is  fully  employed  in 
packs  and  friction  rubs,  spray,  douches,  etc.;  the  enor- 
mously ravenous  appetite  has  been  controlled  and  adjusted 
to  a  lower  proteid  diet,  the  constipation  and  mucocolitis  has 
been  met  by  proper  laxatives  and  colonic  flushes,  and  ordi- 
nary laboratory  tests  are  frequently  requisitioned.  The  lack 
of  muscular  endurance  and  incoordination  is  met  by  setting 
up  exercises,  wood  chopping  and  tending  garden,  wood- 
carving,  and  suitable  games  such  as  tennis,  golf,  medicine 
ball,  and  pool.  As  for  proper  guidance  in  intellectual  devel- 
opment a  course  of  study  in  agriculture  and  the  fundamentals 
of  a  business  education  have  been  outlined  and  used. 
Above  all  and  through  all  runs  the  moral  training  of  proper 
habits  and  obedience  to  the  physical  and  mental  hygiene 
such  as  might  be  expected  of  a  normal  boy  of  his  age.  The 
proper  adjustment  to  a  normal  diversified  life  is  aimed  at 
under  the  wise  guidance  and  supervision  of  the  nurse  and 
physician,  who  strive  to  enter  fully  the  patient's  life  from 
all  aspects  and  help  him  in  best  ways  to  help  himself. 


67 


Section  III. 

A   STUDY   UPON   TWO   SEPTS   OF   FAMILIAL   EPILEPSY,  WITH 

DETAILED  REPORT  UPON  THE  MECHANISM  IN  ONE 

EPILEPTIC  INDIVIDUAL  OF  THE  SERIES. 

Occasionally  opportunity  is  given  to  study  an  entire 
sept  through  several  generations  of  epilepsy.  This  is  a 
matter  of  considerable  importance  in  our  present  day 
understanding  of  the  nature  and  pathogenesis  of  epilepsy. 
During  the  past  few  years  I  have  had  two  such  families 
under  study.  The  first  family  is  comprised  of  the  grand- 
father, who  has  had  but  one  or  two  grand  mal  attacks  in 
his  life  and  who  possesses  the  epileptic  make-up;  and  of  the 
grandmother,  a  confirmed  epileptic  since  her  43rd  year, 
who  has  not  the  epileptic  make-up.  From  this  union  there 
were  four  children:  The  eldest,  a  daughter,  appears  to  be 
perfectly  normal  with  none  of  the  epileptic  character  or 
temperament;  the  next,  a  sou,  is  also  a  healthy,  normal  indi- 
vidual; the  third,  a  son,  is  an  occasional  epileptic  with  little 
of  the  make-up;  the  youngest,  a  daughter,  is  a  confirmed 
epileptic  of  long  standing  and  possesses  the  classic  make-up. 
In  the  case  of  the  latter,  who  married  while  epileptic,  there 
are  two  children,  one  of  which  seems  to  have  the  mother's 
make-up  and  disposition.  Thus  we  have  eight  cases  for 
personality  study. 

The  grandfather  (No.  1)  was  a  poor  boy,  very  energetic 
and  resourceful  mentally,  but  he  possessed  very  little  capac- 
ity to  do  any  practical  work .  Although  people  as  a  rule  liked 
him,  he  was  never  fond  of  them.  He  was  rather  conceited 
and  inclined  to  be  a  leader.  He  was  impatient  and  could 
brook  no  interference  with  any  of  his  plans.  He  had  vio- 
lent tempers  as  a  boy,  and  when  provoked  at  a  great  dis- 
appointment at  the  age  of  twelve  he  had  a  classic  grand 
mal  attack.  He  rapidly  learned  to  control  his  tempers  after 
this  incident.  He  threw  himself  into  his  school  work  and 
finally  entered  on  a  successful  business  career  at  21  years 
of  age,  where  he  found  full  scope  for  his  extraordinary  en- 
ergies.    His  tempers  of  early  life  entirely  disappeared,  and 


68 


(Epileptic)     -j_ 
Possesses 
epileptic 
make-up 


(Epileptic; 


Possesses 
epileptic  make-up 


Chart  I.     Showing  three  generations,  of  which  two  of  the  four  epileptic 
members,  and  one  non-epileptic,  possess  the  classic  "epileptic  make-up." 


69 

he  had  no  more  epileptic  attacks.  His  epileptic  daughter 
resembles  him  very  markedly,  both  physically  and  men- 
tally; they  never  could  agree,  and  were  always  at  odds.  It 
is  said  of  the  father  that  he  has  never  accepted  a  physician's 
statement  that  his  wife  or  children  are  epileptic,  and  when- 
ever it  is  so  affirmed  he  says,  "  Oh,  yes,  the  doctors  think 
they  are  epileptic,  but  they  don't  know."  He  has  never 
interviewed  a  physician  regarding  them  and  ignores  the 
whole  subject  entirely. 

To  summarize,  the  grandfather  is  a  bright,  energetic 
"driving"  type  of  personality,  rigid  and  firm  in  his  disci- 
pline, who  sees  only  the  "things  he  wants  to  see."  He 
had  the  temperament  and  character  make-up  of  the  epileptic 
constitution  but  obtained  the  proper  trend  of  interest  and 
outlet  in  adolescent  and  adult  life,  and  has,  so  far  as  known, 
never  had  another  attack. 

The  grandmother  (No.  2)  is  now  69  years  of  age  and  is  in 
fairly  good  health  aside  from  her  epilepsy.  She  had  her  first 
epileptic  attack  at  43  at  the  birth  of  her  last  child  (No.  6), 
when  she  suffered  a  severe  general  infection  with  ' '  men- 
ingitic  symptoms."  Soon  after,  she  came  under  my  care 
for  classic  grand  mal  attacks,  which  under  the  most  inten- 
sive principles  of  treatment  were  never  greatty  benefited. 
The  attacks  occur  weekly.  There  has  been  very  little  de- 
terioration in  memor}^  or  character,  and  she  lacks  the  epi- 
leptic character  in  any  of  its  settings,  either  in  youth  or  adult 
life. 

The  epileptic  daughter  (No.  6)  was  a  stubborn,  difficult 
child  from  birth.  She  was  rather  lazy  and  sluggish  and 
had  no  power  or  inclination  to  get  square  with  tempers  by 
physical  exercise  or  sport.  She  had  many  tantrums. 
Girls  whom  she  did  not  like  "didn't  exist"   for  her,  and 

she  never  seemed  to  notice  their  presence."  When  com- 
plimented about  her  good  looks  she  would  reply  with  acerb- 
ity, "  You  needn't  tell  me  that;  I  have  my  mirror."  She 
had  few  friends  and  seemed  to  care  little  for  them.  It  was 
easy  for  her  to  take  on  new  acquaintances  if  she  cared  for 
them,  and  quite  as  easy  to  part,  and  she  never  mentioned 
their  names  after  they  had  once  moved  away.     She  never 


70 

forgot  or  forgave  an  injury.  She  was  egotistical  and  super- 
sensitive, and  never  affectionate  or  demonstrative  toward 
any  one.  She  was  indifferent  to  social  life  during  her  stu- 
dent days,  but  stood  well  in  college  classes.  She  made  few 
friends  while  at  school  but  seemed  little  annoyed  about  it. 
She  had  her  first  grand  mal  attack  at  14  after  a  prolonged 
irritation  in  not  being  allowed  by  her  father  to  have  her 
own  way.  She  was  first  repressed,  sullen,  and  then  the 
attack  came  on.  For  years  after  the  attacks  were  in  evi- 
dence, the  relatives  believe  she  delayed  or  put  off  many  of 
them  through  an  escape  b}^  her  music.  Her  speaking  voice 
is  monotonous;  her  singing  is  clear  and  distinct,  but  not 
especially  melodious  or  musical,  and  "something  in  the 
quality  of  expression  is  left  out."  "She  has  none  of  the 
qualities  of  the  mother  in  feeling  or  understanding  ' '  is  the 
statement  of  the  brothers.  She  has  always  lacked  in  verac- 
ity, but  unlike  the  telling  of  exaggerated  stories  by  the  father, 
'she  doesn't  seem  to  know  what  the  exact  truth  is."  At 
the  age  of  24  she  married  socially  beneath  her,  much  against 
the  advice  and  wishes  of  the  whole  family.  The  husband 
knew  she  was  an  epileptic,  and  also  knew  she  would  receive 
no  funds  or  other  considerations  from  the  family.  There  are 
two  children  by  this  marriage:  the  elder  is  very  animated  and 
normal  and  resembles  her  father  (husband  of  No.  6);  the 
younger  daughter,  now  2>%  years  old,  has  the  identical  make- 
up of  the  mother,  and  has  already  shown  the  same  epileptic 
character.  In  comparing  mother  and  daughter  our  inform- 
ant states  that  this  child  "  is  little  M.  all  over  again."  As 
might  be  expected,  the  marriage  has  been  a  failure  after 
seven  years'  trial.  This  is  apparently  due  to  the  fault  of 
the  wife;  and  she  abruptly  left  her  husband  and  children, 
went  back  to  her  own  father's  home,  and  expresses  no  con- 
cern whatever  for  them.  Her  leaving  her  husband  and  his 
home  was  apparently  motiveless;  she  says,  "  I  just  got  tired 
and  left;  maybe  I  will  go  back  again  sometime."  Her  sis- 
ter says  ' '  she  shows  no  evidence  of  mental  deterioration  as 
ordinarily  understood,  but  there  is  a  profound  ethical  and 
moral  degradation  in  the  short  years  of  her  married  life, 
and  yet  they  are  only  her  old  faults  writ  larger  and  more 


71 

indelibly,  and  her  attacks  seem  to  be  but  an  expression  of 
the  whole  lack  of  proper  development."  Since  returning 
to  the  father's  home  she  does  little  but  go  about  and  enjoy 
herself,  and  the  attacks  are  much  less  frequent  and  severe. 
We  will  now  consider  briefly  the  make-up  of  the  brother 
(No.  5)  28  years  of  age,  who  has  had  infrequent  epileptic 
attacks  since  his  eighteenth  year.  He  is  of  a  perfect  robust 
physique  and  probably  has  had  but  six  or  seven  attacks  in 
all,  and  but  three  grand  mal  in  type.  Almost  from  birth 
he  was  considered  a  difficult,  stubborn  child.  When  rep- 
rimanded he  resented  it  and  had  tantrums.  If  punished  he 
"smouldered  with  hate."  At  the  times  of  his  tantrums  his 
mother,  not  being  strong  enough  to  cope  with  the  difficulty 
of  managing  him,  would  pour  cold  water  on  him,  which 
had  the  desired  effect.  His  physical  development  was  not 
retarded  or  imperfect,  but  it  was  noticed  that  he  was  slow, 
but  not  stupid  or  lazy.  He  had  little  interest  in  many  of 
his  studies  and  did  not  seem  to  care.  He  was  always  tu- 
tored, and  his  education  is  not  up  to  his  opportunities.  He 
went  only  one  year  to  college  because  he  simply  did  not 
want  to  go.  He  has  since  been  admitted  to  the  bar  and 
does  corporation  practice  faithfully  and  well.  Since  leav- 
ing college  he  has  mapped  out  his  own  course  and  has 
gotten  on  much  better.  Compared  with  his  father  it  is 
stated  that  he  is  not  so  energetic  as  the  former,  although  as 
he  grows  older  and  shapes  his  own  activities  he  is  growing 
in  this  respect.  In  late  adolescence  he  was  able  to  make  a 
better  social  adaptation,  and  now  is  universally  liked;  he 
never  loses  his  temper.  As  a  child  he  played  freely 
with  other  children,  although  he  had  to  be  handled 
with  a  certain  amount  of  tact.  He  was  affectionate 
and  demonstrative  and  was  never  suspicious  or  mistrust- 
ful, although  easily  offended.  He  was  always  frank  and 
open  but  has  never  cared  to  unburden  himself  and  wants 
to  do  things  in  his  own  way.  Although  cheerful  and  light- 
hearted  in  temperament,  he  becomes  easily  depressed.  His 
emotional  reactions  to  daily  life  are  shown  in  his  ' '  being 
way  up  or  way  down."  Since  being  in  business  he  has 
grown  a  little  more  irritable,  and  he  often  comes  home  and 


72 

says,  "  I  have  just  smiled  all  day  long,  and  I  can  not  smile 
any  more."  His  irritation  lasts  but  a  short  time  now,  and 
can  be  gotten  square  with  by  music  and  social  intercourse 
with  his  friends. 

The  sister  says,  in  regard  to  the  temperamental  make-up 
of  this  brother,  that  he  has  some  of  the  characteristics  of 
both  parents.  Like  his  father  he  is  supersensitive  and  ego- 
istic, wants  good  food  and  clothes  and  likes  to  spend  freely; 
but  he  gets  the  refinements  of  his  nature  from  his  mother. 
His  appreciation  of  beauty,  music,  flowers,  architecture, 
etc.,  is  from  her,  and  undoubtedly  helps  him  out  in  '"tight 
places."  His  present  position  is  thought  to  be  quite  a 
strain,  with  the  hurry  and  bustle  of  business  requirements. 
Since  he  became  epileptic  he  was  jilted  by  the  girl  to  whom 
he  was  engaged,  and  took  the  situation  very  hard;  he  cried 
and  trembled  violently;  a  convulsion  seemed  threatened  but 
none  occurred.  He  then  went  away  for  several  days  to 
visit  friends,  enjoyed  himself,  and  very  soon  was  apparently 
all  over  it.  About  three  years  ago  a  grand  mal  at- 
tack occurred,  at  a  time  when  he  was  much  worried,  had 
slept  little,  and  was  obliged  to  go  without  his  breakfast  on 
a  particularly  cold  day.  It  is  said  of  him  that  he  goes  on 
the  theory,  ' '  I  will  go  ahead  anyway,  no  matte?'  what  hap- 
pens.'" He  keeps  to  no  physical  or  hygienic  regulations 
and  is  probably  on  the  way  to  a  later  epileptic  career,  al- 
though his  resources  of  adjustment  by  way  of  music  and  the 
arts  have  enabled  him  to  get  square  with  the  irritation  and 
annoyances  of  daily  life  fairly  well.  Having  started  in  life 
with  the  epileptic  character,  he  found  vicarious  outlets  and 
trends  of  interest  sufficient  to  relieve  the  irritable  tension; 
finally,  since  he  has  gone  his  own  way,  he  has  had  in- 
frequent attacks  and  those  mostly  of  the  petit  mal  type.  In 
just  such  cases  the  most  hopeful  prognosis  may  be  enter- 
tained if  the  patient  can  be  influenced  to  lead  the  proper 
life,  satisfying  and  non-irritating,  with  plenty  of  emotional 
outlets  of  interest  to  balance  the  sensitiveness  of  the  indi- 
vidual make-up.  Of  course  ordinary  physical  and  mental 
hygiene  should  also  be  maintained. 

A  minute  detailed  examination  of  the  remaining  two  in 


73 

the  family,  sister  and  brother  (No.  3  and  No.  4),  reveals 
none  of  the  character  of  the  epileptic  make-up  and  is  not 
sufficiently  interesting  from  a  pathologic  standpoint  to 
warrant  detailing  here. 

To  summarize  this  family  as  a  group,  one  sees  that  the 
grandfather  had  but  one  or  possibly  two  grand  mal  attacks, 
but  nevertheless  possessed  the  classic  epileptic  make-up.  He 
had,  however,  the  innate  capacity  of  life  adjustment  to  save 
him  from  further  manifestations  of  outspoken  epilepsy.  The 
grandmother  probably  contracted  a  meningitic  lesion  which 
took  on  an  epileptic  reaction  of  the  symptomatic  or  organic 
type  in  the  apparent  absence  of  the  epileptic  make-up.  Of 
the  children  from  this  union,  two  are  epileptic,  the  one  girl 
with  the  classic  make-up  and  classic  attacks;  the  brother, 
with  about  the  same  initial  defect  in  instincts  as  the  sister, 
began  early  to  make  better  adaptations  and  has  succeeded 
in  overcoming  the  character  in  greater  part,  but  not  quite, 
and  therefore  he  still  pays  for  the  defect  by  occasional  epi- 
leptic reactions.  The  other  sister  and  brother  in  the  family 
possess  none  of  the  epileptic  character  and  are  quite  im- 
mune from  any  epileptic  manifestations.  The  married 
epileptic  daughter  has  one  child  with  classic  make-up  akin 
to  her  own,  and  everything  will  be  done  to  conserve  this 
child  from  epileptic  reactions  in  later  life.  The  unmarried 
sister  has  a  true  insight  into  the  nature  of  the  situation  and 
is  able  and  willing  to  devote  her  life  to  bringing  up  the  epi- 
leptic sister's  children  in  a  healthy  manner.  I  may  say  that 
I  have  had  opportunity  to  examine  carefully  all  the 
members  of  this  family-group,  with  the  exception  of  the 
grandfather. 


The  second  family  group  consists  of  but  two  cases  of  pro- 
nounced epilepsy  in  two  of  the  three  generations  under 
observation.  The  grandmother  (No.  2  on  chart),  one  of  my 
patients,  is  now  50  years  old,  and  contracted  her  epilepsy  at 
33  years  of  age.  The  attacks  have  occurred  three  or  four 
times  a  year  in  a  series  of  three  to  four  grand  mal  at  each 
period.  She  was  born  of  a  neurotic  family  stock.  Her 
mother  was  a  resourceful,  masterful  woman,  and  the  neu- 


74 


Possesses  partial 
epileptic  make-up 


Possesses 

epileptic 

make-up 

(Epileptic) 


Possesses 
epileptic 
make-up 


(Epileptic) 


Possesses 
epileptic 
make-up 


Chart  II.     Showing  three  generations,  of  which  the  two  epileptic   members,  and 
two  non-epileptics,  possess  the  "epileptic  make-up." 


75 

rotic  element  seemed  most  dominant  in  the  mother's  brothers, 
all  of  whom  had  violent  tempers — one  in  particular  is 
said  to  have  gotten  into  uncontrollable  rages  in  which  he 
hurled  abusive  language,  and  afterwards  would  attempt  to 
mollify  the  recipient  of  his  abuse  by  handing  him  a  ten  dol- 
lar bill.  The  patient  herself  had  several  brothers  who  are 
said  to  have  inherited  their  temperament  from  the  maternal 
side.  She  was  a  petted,  spoiled  child  from  birth,  being  the 
only  girl  in  a  family  of  several  boys,  and  the  latter  together 
with  the  parents  supplied  all  her  needs  and  gratified  her 
merest  whims.  She  had  a  proud,  imperious  disposition,  but 
as  it  was  never  thwarted  there  was  no  evidence  of  what 
might  have  happened  if  it  had  been.  She  was  not  atten- 
tive in  school  and  never  applied  herself  seriously.  Her 
school  standing  was  very  indifferent,  and  her  general  edu- 
cation was  not  up  to  her  opportunities.  She  had  a  final 
fashionable  boarding-school  education.  She  was  slow  in 
making  up  her  mind,  was  impractical,  and  was  slavishly 
fond  of  her  mother,  now  dead  a  score  of  years  but  whose 
previously  expressed  thoughts  and  principles  she  follows  out 
as  carefully  as  though  she  still  lived.  Her  point  was  ever 
to  be  dignified  and  not  show  emotions.  She  was  never  de- 
monstrative toward  anyone,  her  mother,  her  husband  or  her 
own  children.  She  always  chose  her  own  gifts,  was  always 
critical,  and  often  "pouted"  at  fancied  slights.  All  her 
life  she  has  had  no  conception  of  punctuality,  can  not  man- 
age little  things  or  situations,  and  seems  rather  surprised 
when  others  are  able  to  accomplish  these  things.  If  she 
is  hurried  she  becomes  flustered,  and  it  is  said  that  "she 
just  goes  her  own  sweet  way  and  lets  the  other  fellow  wait." 
Everyone  about  her  bows  to  the  inevitable,  and  thus  every- 
thing moves  smoothly.  When  flustered  she  seems  lost  for  a 
time,  says  nothing  and  does  nothing,  and  "there  is  just  an 
extreme,  placid  calm  on  her  face."  When  others  who  have 
been  delayed  and  annoyed,  storm  and  protest,  she  herself 
remains  serene  and  sweet  through  it  all,  and  never  loses  her 
temper.  Nothing  seems  to  be  known  of  her  inner  life  as  a 
child  or  in  girlhood,  and  she  herself  says  there  was  nothing 
especially  thought  or  felt  during  that  period.     In  later  ado- 


76 

lescence  she  was  very  morbid  and  liked  funerals,  and  she 
would  never  miss  a  funeral  if  she  could  manage  to  get  to  it. 
Once  she  had  charge  of  the  funeral  of  a  man  whose  wife 
was  her  dearest  friend.  The  remains  were  three  or  four 
days  in  coming  home,  but  she  insisted  on  having  the  casket 
opened  to  satisfy  her  curiosity  when  it  arrived.  She  likes 
to  be  around  people  who  are  ill,  and  exhibits  a  sort  of  mor- 
bid curiosity.  In  caring  for  the  sick  she  experiences  a  keen 
sense  of  fulfilling  her  duty.  When  her  mother  died  she  in- 
sisted on  helping  to  dress  her,  although  there  was  no 
necessity  of  her  assistance.  When  anything  happens  she 
keeps  her  dignity  very  well;  she  very  rarely  cries,  and  never 
gets  excited.  At  one  time  her  daughter  was  seriously  ill, 
and  through  it  all  she  remained  very  quiet,  dignified  and 

brave. ' '  She  is  inclined  to  take  life  over-seriously .  When 
anything  unusual  is  going  on,  she  hates  to  be  cheated  out 
of  it;  for  instance,  she  was  furious  because  she  was  not  in- 
formed in  time  to  be  with  the  daughter  when  her  child  was 
born,  and  stated  emphatically  that  she  "  did  not  want  to  be 
saved  from  the  ordeal."  She  has  no  sense  of  humor,  and 
is  not  optimistic.  She  feels  neglected  if  the  daughter  fails 
to  telephone  each  morning  to  ask  how  she  is,  although  her 
answer  is  invariably,  "Oh,  so-so,"  and  she  never  says  she 
feels  fine.  She  takes  pleasure  and  good  news  very  quietly,  and 
has  never  been  known  to  be  jovial  or  enthusiastic.  She  took 
up  a  little  settlement  work,  and  rather  enjoyed  hearing  hard 
luck  stories  but  never  really  entered  into  the  spirit  of  the 
work.  She  is  fond  of  the  theatre,  but  always  likes  to  be 
coaxed,  even  to  do  the  things  she  enjoys  doing. 

When  her  daughter  married  she  did  not  quite  know  how 
to  meet  the  situation.  She  had  previously  disapproved  of 
the  match,  and  did  not  want  to  greet  the  son-in-law  as  a 
friend,  nor  yet  to  recognize  him  as  a  son-in-law.  She  seemed 
to  be  waiting  to  know  her  husband's  viewpoint  and  depend- 
ing on  his  attitude,  and  in  the  meantime  she  was  simply 
lost.  She  is  now  devoted  to  this  son-in-law,  and  the  latter 
brings  a  great  deal  of  enjoyment  into  her  life. 

She  takes  real  troubles  very  hard  and  can  not  get  over 
them.     She  is  very  conventional  in  her  grief.     She  insisted 


77 

upon  wearing  mourning  for  a  year  when  her  mother  died, 
even  though  her  brother,  a  physician,  requested  her  not  to 
do  so.  After  three  or  four  months  had  elapsed  she  con- 
sented to  go  to  the  theatre  after  a  good  deal  of  urging.  She 
argued  that  if  the  mother  were  alive  and  could  be  consulted 
she  would  expect  her  to  wear  mourning.  It  seemed 
absolutely  to  be  a  matter  of  going  against  convention  rather 
than  any  depth  of  feeling.  She  was  pedantic,  phlegmatic 
and  rigid,  and  could  not  be  moved.  Her  husband  almost 
went  down  on  his  knees  begging  her  to  resume  her  life,  to 
go  about  and  follow  her  usual  activities,  but  it  took  months 
before  he  succeeded  in  having  her  do  it;  she  still  continued 
to  wear  mourning,  however,  after  she  finally  consented  to 
go  about  socially  as  the  others  did.  She  always  felt  sorry  for 
herself,  yet  would  not  have  had  things  otherwise  for  the 
world;  she  just  luxuriated  in  her  woe.  She  now  procrasti- 
nates in  moving  from  her  present  home,  and  sighs  deeply  at 
the  thought  of  making  a  change.  She  is  not  religious  and 
derives  no  comfort  from  religion,  but  goes  to  church  once  in 
a  great  while  as  she  wishes  to  be  "represented."  At  the 
grave  of  her  mother  (who  had  been  an  invalid  for  years) 
she  was  very  calm.  The  daughter  once  roused  her  to  great 
anger  by  saying  she  hoped  she  would  never  live  to  be  old 
and  decrepit.  Our  patient  said  it  was  a  terrible  thing  to 
say  and  reflected  on  the  grandmother.  She  said:  "if 
you  feel  that  way,  I  hope  I  never  will."  She  clings 
tenaciously  to  tradition  and  is  very  reactionary  in  civic,  re- 
ligious and  social  views.  She  often  remarks:  "I  do  not 
think  anyone  could  have  improved  on  the  way  my  mother 
brought  up  her  family.  "  She  does  not  like  the  idea  of  go- 
ing away  from  home,  yet  becomes  a  different  woman  when 
she  can  be  urged  to  do  so.  The  husband  came  home  one 
afternoon  after  she  had  been  preparing  for  two  weeks  to  go 
to  a  distant  city  to  consult  a  physician,  and  said  he 
thought  it  best  to  start  that  night.  She  replied:  "No,  I 
can't  go  to-night;  the  laundry  isn't  put  away  yet." 

At  present  she  has  no  intimate  friends  excepting  those 
who  have  taken  a  strong  liking  to  her  and  with  whom  she 
plays  bridge.     She  is  very  kind  and  thoughtful  of  them; 


the  others  are  mostly  family  ties.  She  has  a  stupendous 
family  pride  and  is  ' '  forever  talking  about  her  ancestors 
and  their  ancient  achievements." 

Now,  upon  this  extraordinarily  supersensitive  and  child- 
like make-up  were  thrown  three  great  emotional  crises,  and 
we  shall  see  their  results.  The  first  was  a  romatic  fancy 
for  an  elderly  friend  of  her  brothers.  When  this  friend  be- 
came engaged  she  became  depressed,  was  sleepless,  lost  her 
appetite,  and  had  "faints"  (probably  petit  mal  in  char- 
acter from  the  description).  She  stayed  at  home  and 
remained  in  bed  for  two  or  three  months.  Under  special 
mental  treatment  and  distractions,  which  finally  ended  in  a 
change  of  scene,  the  episode  was  passed.  The  second  trial 
occurred  some  three  or  four  years  before  her  first  grand  mal 
attack.  She  married  at  24,  some  six  years  after  the 
"first  love  affair."  Sexual  intercourse  was  painful  and 
always  unpleasant.  Her  first  child,  a  girl,  at  7  years  of 
age  contracted  spinal  curvature,  and  the  mother  then  came 
out  of  her  "eternal  calm"  and  worried  about  it  continually, 
night  and  day.  She  slept  poorly,  lost  in  weight,  was  fear- 
ful, depressed,  and  had  anxious  dreams.  She  has  always 
admired  erect  persons,  and  possesses  a  beautiful  physique 
herself.  She  has  always  admonished  her  son  to  stand 
erect,  sit  straight,  etc.  Four  of  her  brothers  had  good 
physiques,  and  two  had  not;  one  brother  had  scarlet 
fever,  and  this  affection  left  him  with  a  weak  back 
but  he  finally  overcame  it  and  carried  himself  well; 
the  youngest  brother  has  one  shoulder  higher  than  the 
other.  Her  own  mother,  who  was  a  little  round-shouldered 
in  later  years,  had  been  considered  a  very  handsome  woman 
and  was  married  at  16.  Our  patient  says:  "I  could  not 
bear  the  thought  that  a  daughter  of  mine  should  have  other 
than  a  perfect  physique;  this  has  been  our  family  pride,  and 
it  seemed  as  though  my  only  daughter  should  not  break  the 
traditions  in  this  respect;  the  idea  was  unbearable."  She 
then  began  to  take  the  daughter  to  many  physicians.  Even 
though  the  daughter  pleaded  that  she  was  satisfied  with  the 
treatment  she  was  getting,  the  mother  would  turn  to  her 
sharply  and  say:      ' '  I  don't  want  you  to  grow  up  and  accuse 


79 

me  of  not  doing  all  I  could  for  you."  To  the  mother  the 
whole  affair  was  unendurable,  and  though  the  curvature  was 
finally  controlled  she  continued  to  worry,  and  this  ended  in 
an  attack  of  grand  mal.  She  has  gradually  become  recon- 
ciled to  the  daughter's  defect,  but  with  a  continued  epilep- 
tic reaction  whenever  stressful  periods  supervene.  The  third 
period  of  mental  stress  was  when  her  only  son  was  pro- 
nounced epileptic,  at  which  time  a  series  of  attacks  occurred. 
For  the  past  nine  months,  since  the  son  has  shown  a  marked 
improvement,  she  has  had  but  one  attack,  whereas  half  a 
dozen  might  have  been  expected. 

To  summarize,  we  have  here  the  history  of  a  rigid  and 
supersensitive  woman,  who  was  given  no  adaptive  or  ad- 
justment training  or  education;  who  was  self- centered,  re- 
pressed, and  so  slavishly  attached  to  her  mother  that  she  has 
continued  emotionally  infantile  throughout  life  ;  one  who 
has  never  accustomed  herself  to  handling  any  strong  emo- 
tional episode  without  epileptic  reactions.  Her  husband 
says,  "She  is  too  sensitive  to  the  rude  winds  of  life,  and 
must  be  protected  from  them  as  much  as  I  can  make 
possible  for  her."  We  may  say  in  passing,  that  we  have 
followed  his  lead,  and  she  has  been  advised  to  give  up 
housekeeping  and  to  take  up  an  active  outdoor  life,  which 
she  has  always  liked  and  wanted  to  do.  In  addition  she  is 
living  under  a  regime  of  as  good  physical  and  mental 
hygiene  as  possible. 

We  shall  now  pass  on  to  the  son's  case  (No.  4).  He  is 
now  24  years  old  and  began  his  epileptic  career  at  15,  with 
minor  attacks  or  absences  which  finally  terminated  in  grand 
mal  attacks  at  18.  In  the  petit  mal  attacks  he  first  experi- 
ences a  feeling  of  tightness  in  the  stomach,  and  a  sense  of 
uneasiness  as  though  gas  were  present  there;  then  he  won- 
ders whether  he  is  going  to  have  a  sensation  and  becomes 
interested  to  see  how  it  will  end  and  whether  a  sensation 
will  develop  or  not.  After  this  there  is  a  feeling  of  dryness 
of  the  mouth  and  tongue — a  condition  similar  to  that  which 
he  has  experienced  when  keyed  up  for  examinations,  at  a 
school  recitation,  or  when  something  hard  has  to  be  accom- 
plished, especially  if  it  has  to  be  done  in  a  hurry.     Then 


80 

there  is  a  heightened  sense  of  subjectivity,  and  homesick- 
ness and  lonesomeness  succeed.  The  above  takes  place  in 
an  incredibly  short  time,  and  then  a  "wave  ' '  occurs. 

Just  before  the  sensations  are  to  occur  the  patient  often  feels 
a  lack  of  rapport  with  those  whom  he  may  be  with  and  a 
sense  of  indifference  or  boredness  follows  in  which  he  feels 
a  heightened  sense  of  his  own  body  and  mind,  and  a  ' '  de- 
tachment from  others  about  him"  (increased  subjectivity). 
There  often  follows  a  sensation  of  ' '  disgust ' '  in  the  pit  of 
his  stomach,  which  is  always  directed  toward,  or  felt  for, 
his  surroundings  and  the  people  about  him.  The  indiffer- 
ence exists  long  before  there  are  "waves"  or  other  actual 
epileptic  symptoms:  they  occurred  especially  in  the  absent- 
minded  states  of  which  his  mother  complained  when  he  was 
a  small  boy  and  which  were  often  spoken  of  as  states  of 
absentmindedness.  These  states  are  now  attended  by  con- 
fusion or  loss  of  consciousness;  otherwise  they  are  identical 
with  the  earliest  habits  described.  First  there  is  a  feeling 
of  apprehension,  then  staring,  and  disgust;  secondly,  a  feel- 
ing of  pleasurable  amiableness  and  contentment.  As  the 
petit  mal  departs  there  is  an  irritable  depression  in  which 
the  patient  seems  to  want  to  be  undisturbed,  and  as  though 
he  were  "trying  to  remember  or  wishes  to  finish  something" 
before  coming  back  to  the  everyday  conscious  state. 

From  earliest  infancy  he  was  a  stubborn,  difficult  child 
and  had  frequent  tantrums  all  through  his  childhood.  In 
his  best  periods,  however,  he  was  generous,  kind-hearted, 
thoughtful,  and  affectionate.  As  a  child  he  was  fond  of 
romancing  and  if  anyone  interrupted  him  he  would  start  all 
over  again  at  the  beginning.  He  was  inclined  to  wander 
from  the  point,  and  simply  could  not  speed  up  his  mental 
action.  It  was  noticed  early  in  life  that  he  had  what  is 
known  as  the  epileptic  voice  sign.  His  speech  was  scan- 
ning, with  an  irregular  phrasing  of  his  sentences. 
While  he  was  lively  as  a  child  he  never  coordinated 
fast  or  well.  He  was  a  fat  boy,  constipated  and  had  poor 
physical  endurance.  His  mind  was  never  rich  in  ideas  but 
he  could  accumulate  facts.  While  he  learned  easily  he 
never  did  things  that  were  especially  original  or  clever.     He 


81 

never  weiit  into  anything  deeply.  If  he  had  an  idea  and 
was  balked  in  carrying  it  out  he  never  argued  or  teased 
about  it;  he  at  once  threw  himself  on  the  floor  and  went 
into  a  tantrum.  He  was  supersensitive  and  never  could 
bear  disappointment  of  any  kind,  and  this  has  always  been 
his  peculiar  temperament.  He  was  alwaj^s  afraid  of  getting 
sick,  or  being  poisoned,  and  he  could  not  bear  the  sight  of 
blood.  Aches  and  pains  bothered  him  a  good  deal,  and  in 
any  illness  he  always  felt  very  sorry  for  himself.  After  the 
tantrums  there  was  always  a  sense  of  relief,  never  any 
moroseness  or  sulking.  However,  if  he  really  wanted  a 
thing  he  made  up  his  mind  to  get  it,  and  was  never  known 
to  be  sidetracked  or  to  give  up  the  idea  of  getting  the  de- 
sired object.  Even  when  he  had  reached  the  age  where  he 
could  be  reasoned  with,  he  would  still  "  fly  off  the  handle." 
When  the  sister  was  asked  what  caused  his  epilepsy  she 
said,  "  I  suppose  the  minor  attacks  are  but  the  forerunners 
of  the  severe  ones,  and  that  the  former  came  on  as  a  part 
expression  of  his  lack  of  proper  mental  development.  His 
mind  did  not  grow  with  his  body.  First,  the  tantrum  epi- 
sodes were  an  expression  of  his  inability  to  get  square  with 
things;  later,  the  attacks  of  anger  replaced  the  earlier  child- 
tantrums.  When  the  anger  episodes  were  not  sufficient  to 
express  his  mental  attitude,  the  abstractions  came  up  and 
then  the  attacks  followed." 

While  the  sister  (who  has  a  somewhat  similar  make-up) 
went  to  the  father  to  straighten  things  out,  our  patient  went 
to  the  mother  to  get  his  desires  satisfied.  The  mother  never 
reasoned  with  him  or  explained  the  difficulty  away  and 
rarely  yielded  to  his  desires,  and  yet  he  never  went  to  the 
father  who  handled  such  situations  quite  differently.  Our 
patient's  difficulties  were  largely  on  ethical  grounds;  he 
could  or  would  not  make  a  compromise  with  necessity,  and 
consequently  he  was  a  "much  disappointed  boy."  His 
conflicts  largely  came  about  because  he  always  had  a  latent 
desire  to  do  things  only  in  a  certain  way — any  other  way 
would  not  do,  and  to  be  opposed  or  directed  generated  heat. 
When  he  was  allowed  to  do  as  he  pleased  he  was  smiling  and 
happy  and  went  about  whistling.     Even  when  any  contro- 


82 

versies  came  up  with  the  neighborhood  boys  he  went  ' '  all 
to  pieces, ' '  threw  up  the  game,  and  would  not  play. 

A  sample  of  the  day-dreaming  of  earliest  childhood  is 
shown  in  the  patient's  statement  that  when  he  was  very 
young  he  found  great  pleasure  in  being  near  his  mother, 
and  at  such  times  he  would  seem  to  forget  everything  and 
apparently  wander  off  in  thoughts  of  his  own;  he  was  con- 
scious of  all  that  went  on  and  could  hear  any  conversation 
that  was  being  held,  but  would  not  join  in  it  and  did  not 
have  the  desire  to  do  so.  His  mother  on  these  occasions 
would  scold  him  and  tell  him  he  looked  foolish  staring  into 
space.  As  he  recalls  these  flights,  he  says  that  they  were 
pleasant  and  satisfying. 

Something  of  the  nature  of  our  patient's  social  reactions 
in  his  ' '  deep  down  ' '  dislike  of  his  associates  who  do  not 
fully  meet  his  nice  conception  of  society,  and  the  beginning 
mental  settings  leading  up  to  a  series  of  attacks,  may  be 
gained  from  the  following  and  other  notes.  They  are  taken 
from  the  close  study  of  our  patient  after  he  had  joined  the 
club  for  detailed  observation  and  a  training  treatment. 

While  under  observation  the  patient  went  through  a 
period  in  which  he  became  rather  quiet  and  made  no  effort  to 
join  the  general  conversation  unless  directly  addressed.  He 
remarked  that  he  was  ' '  not  at  all  homesick, ' '  but  frequently 
referred  to  home  and  said  he  wished  he  were  going  home 
instead  of  with  the  rest  of  the  group  to  the  country.  On 
being  asked  his  views  relative  to  the  different  members  of 
the  group,  with  whom  he  was  thrown  in  contact,  he  said 
that  Mr.  A.  possessed  a  childish  personality  he  could 
not  like,  and  that  he  had  no  patience  with  him  and 
found  it  annoying  to  be  in  his  company.  He  then  said 
there"  were  very  few  in  the  group  he  cared  to  associate 
with  as  he  considered  them  not  up  to  the  mental  standard 
their  age  would  demand.  He  liked  Miss  X.,  whom  he  con- 
sidered far  superior  to  the  other  patients,  and  also  derived 
enjovment  from  the  society  of  two  male  nurses.  On  the 
whole^he  found  the  other  guests  rather  boresome,  and  did 
not  care  to  associate  with  them  for  that  reason.  Although 
it  was  apparent  that  he  was  homesick,  the  patient  himself 


83 

attributed  his  disagreeable  feelings  to  his  associates.  He 
said  he  knew  it  was  wrong  to  let  this  feeling  get  the  better 
of  him  and  he  would  try  to  forget  it,  but  "it  was  hard  to 
do  so  when  such  conditions  were  present." 

To  show  that  such  superficial  rationalizations  and  a  de- 
sire to  overcome  his  attitude  only  stirred  the  surface  of 
things,  we  note  that  although  our  patient  became  cheerful 
and  happy  and  talked  freely,  nevertheless  he  repeatedly  ex- 
pressed his  desire  to  be  going  home  instead  of  preparing 
for  a  summer  in  the  country,  and  within  twenty-four  hours 
he  had  a  series  of  petit  mal  and  grand  mal  attacks.  Fol- 
lowing these  attacks  the  patient  was  decidedly  more  cheer- 
ful, and  the  marked  depression  so  apparent  in  the  early 
hours  seemed  to  pass  slowly  away. 

When  asked  to  describe  the  feeling  that  gave  him  the 
warning  of  approaching  trouble  the  patient  at  once  began 
to  hesitate  and  replied,  "Why — it's  like  a — a  feeling  of 
(frowning  and  making  motion  with  index  finger  and  an 
expression  of  annoyance) — like  gas  passing  or  trying  to  get 
out."  Although  able  to  talk  freely  after  the  attacks,  pro- 
vided the  conversation  does  not  apply  to  the  cause  of  the 
disturbance,  if  this  subject  is  brought  up  he  at  once  frowns 
and  has  great  difficulty  to  describe  what  he  feels  at  such  a 
time.  In  point  of  fact,  it  is  indescribable,  and  hence  prob- 
ably quite  unconscious. 

The  patient's  infantile  attitude  toward  the  mother- father 
complex  is  shown  in  many  ways.  For  instance,  while  vis- 
iting with  relatives  he  preferred  to  spend  his  time  with  the 
women,  and  sat  near  the  aunt  and  held  her  hand.  Fre- 
quently on  going  out  for  a  short  while  he  kissed  each  one, 
and  again  on  his  return.  When  talking  to  the  male  relatives 
he  assumed  an  attitude  of  submission,  he  allowed  them  to 
do  all  the  talking,  and  agreed  with  them  in  all  things;  he 
was  timid,  blushed  easily,  and  made  no  effort  to  speak  with 
authority  while  conversing  with  them. 

As  a  young  boy  the  patient's  greatest  friends  were  a 
family  of  six  boy  cousins,  who  were  allowed  many  privi- 
leges which  appealed  to  the  patient  but  of  which  his 
parents  did   not    approve,  such  as  playing   cards,  staying 


84 

out  late,  etc.  When  the  patient  did  these  things,  he 
was  reprimanded;  while  he  considered  that  he  had  done 
no  wrong,  he  knew  he  would  be  brought  to  task  and 
brooded  over  the  situation  from  day  to  day.  When  in 
company  with  his  cousins  he  was  told  that  he  inter- 
fered with  their  pleasure  because  he  wanted  to  go  home 
too  early,  and  rather  than  offend  them  he  would  remain, 
saying,  "Well,  I'm  in  for  it  again."  When  he  reached 
home,  no  matter  what  the  time  was,  his  father  or  mother 
would  always  call  to  him  and  ask  where  he  had  been. 
If  he  happened  to  slip  in  without  being  heard  he  knew  he 
was  sure  to  be  catechized  in  the  morning.  This  state  of 
affairs  began  when  he  was  twelve  years  old,  and  became 
more  unbearable  as  he  grew  older.  Previous  to  the  age  of 
twelve  the  patient  recalls  that  when  he  fought  with  his 
sister  he  was  usually  blamed  for  causing  the  trouble,  the 
parents  as  a  rule  taking  the  sister's  part. 

For  many  years  the  patient  was  conscious  of  "being  held 
within  bounds  ' '  and  resisted  being  in  this  position  and  pre- 
ferred the  freer  life  his  cousins  lived.  His  parents  were 
very  nervous  and  nagging,  and  he  now  states  that  they 
were  wrong  to  be  so  strict,  and  that  it  was  their  own  con- 
dition that  brought  about  his  attacks.  A  member  of  the 
family  states  that  the  patient  was  chastized  many  times  for 
remaining  out  late,  because  the  parents  were  afraid  some- 
thing might  happen  to  him;  he  exhibited  a  violent  temper 
and  they  found  it  very  difficult  to  control  him.  In  a  free 
monologue  our  patient  gives  the  following  family  setting  as 
being  responsible  for  bringing  on  many  attacks. 

"When  I  had  my  first  attack,  my  parents  consulted  a 
physician,  who,  after  giving  me  a  careful  examination, 
began  to  talk  to  me,  and  during  the  conversation  he  said  I 
ought  not  to  go  with  my  boy  cousins.  How  could  he  have 
known  about  them  if  my  parents  had  not  told  him?  Later 
my  cousins  told  me  I  should  not  go  with  them  because  I 
was  sick  and  should  live  more  in  the  open,  and  that  I  could 
not  do  this  and  continue  to  associate  with  them.  I  knew 
that  my  father  had  told  them  to  talk  to  me  in  this  way;  I 
felt  as  if  my  parents  nagged  me,  and  wrongly,  because  I 


8.5 

would  have  been  so  much  better  off  had  they  allowed  ine  to 
go  my  own  way."  The  continued  interference  with  the 
manner  in  which  he  wished  to  lead  his  life  caused  another 
outburst  of  attacks  immediately  after  he  was  placed  under 
medical  attention. 

To  return  to  more  recent  settings:  After  a  period  of  clear 
mental  skies,  the  irreconcilable  attitude  toward  the  social 
setting  of  the  club  was  again  in  evidence,  but  after  he  had 
talked  over  the  various  situations  and  become  more  con- 
sciously adjusted,  the  attacks  became  less  in  evidence. 
One  evening  after  supper  the  patient  said  he  would  like  to 
talk  with  the  nurse  about  something  which  he  had  men- 
tioned several  times  before.  He  started  by  saying,  "Now, 
B.,  don't  you  think  that  A.  is  awfully  tiresome?"  When 
the  nurse  admitted  that  A.  and  all  the  rest  of  the  group 
were  tiresome  but  all  in  a  different  degree,  the  patient 
smiled  and  said,  "Yes,  I  know  that;  and  I  am  trying  to 
get  so  I  will  not  talk  sharply  or  crossly  to  A.  when  I 
have  to  talk  to  him. "  He  added  that  he  was  getting  to  see 
many  good  points  in  Z.  that  he  had  never  seen  before,  to 
which  the  nurse  replied  that  he  would  soon  begin  to  see 
some  good  in  everyone,  that  it  was  onty  a  matter  of  prop- 
erly adjusting  himself  to  his  surroundings  and  getting  to 
understand  the  different  dispositions.  The  patient  said  he 
was  trying  hard  to  do  this,  but  that  there  were  some  things  that 
kept  popping  up  every  now  and  then  that  were  disagreeable 
and  did  not  appeal  to  him,  but  that  after  a  talk  with  the 
nurse  or  physician  he  was  able  to  minimize  their  import- 
ance. After  such  conversations  the  patient  is  generally 
more  cheerful,  appears  to  have  gotten  some  mental  relief, 
and  makes  a  conscious  effort  to  follow  out  the  advice  given. 

Next  day,  on  reading  over  his  mail,  the  patient  went 
around  pouting  like  a  child,  and  talking  only  when  ad- 
dressed. Later  he  said  he  had  received  several  letters,  all 
telling  him  of  the  good  times  going  on  at  home  and  what  he 
was  missing.  At  dinner  he  seemed  unable  to  hold  in  any 
longer,  and  told  the  nurse  that  he  could  not  help  it  if  he 
was  grouchy  when  he  got  letters  and  invitations  from  the 
West  telling  him  of  all  the  good  times  going  on    there. 


86 

When  told  he  should  not  allow  this  to  depress  him,  but 
work  all  the  harder  to  get  better  so  that  he  could  return  and 
join  in  the  good  times,  and  in  the  meantime  to  rejoice  that 
his  friends  were  having  such  an  enjoyable  time,  he  said, 
"Well,  what  about  me?  That  doesn't  do  me  any  good;  I 
don't  care  about  them  as  long  as  /  have  a  good  time." 
After  a  while  he  smiled  and  said,  "Well,  I  suppose  I  am 
acting  like  a  kid,  but  it  makes  me  sore  to  be  missing  every- 
thing. "  A  few  hours  later  he  had  a  mild  attack.  He  was 
cheerful  the  following  day,  but  it  was  evident  that  the 
slightest  indisposition  caused  him  to  become  moody,  grouchy 
and  uncommunicative.  The  next  day  he  had  a  very  mild 
attack  in  the  early  morning,  and  on  recovering  and  being 
questioned  by  the  nurse,  he  smiled  in  an  offhand  manner 
and  said,  "Oh,  I  had  just  a  little  attack."  He  at  once  be- 
came moody,  and  when  spoken  to  by  A.  he  made  no  an- 
swer at  all.  He  went  about  showing  his  displeasure  at 
everything  but  made  no  comments.  The  patient  becomes 
very  much  depressed  over  the  attacks,  and  blames  himself  for 
his  weakness  in  not  being  able  to  ward  them  off.  At  the  same 
time  he  admits  that  he  encourages  them  to  come  on  for  the 
reason  that  it  is  a  disagreeable  feeling  and  better  out  of  his 
system.  "  It  is  just  like  a  sneeze,  not  at  all  pleasant  coming 
on,  but  when  over  gives  a  sense  of  relief." 

There  is  an  excellent  exposition  of  the  wish  motive  in 
the  minor  attacks  and  the  sympathetic  pitying  appearance 
of  the  person  hallucinated,  who  is  always  his  "good 
friend."  When  the  attack  goes  deeper,  however,  the  whole 
situation  becomes  unmanageable  and  he  seems  to  retreat 
into  a  "goneness  "  that  is  often  described  as  something  that 
"draws  him  down  or  in."  Often  now  during  the  minor 
attacks  he  suddenly  thinks  of  someone — his  mother,  father, 
nurse,  or  some  of  the  guests.  He  seems  to  be  suddenly 
transferred  to  the  presence  of  this  person,  who  appears  to 
be  looking  at  him  with  a  look  of  infinite  sadness,  which 
greatly  distresses  him.  He  does  not  know  why  he  feels  so 
distressed  at  the  manner  in  which  they  confront  him,  but 
the  persons  that  are  hallucinated  always  seem  to  need  his 
sympathy. 


87 

Three  characteristic  episodes  that  are  quite  instructive 
will  now  be  incorporated  in  this  patient's  report.  The  first 
followed  a  rather  prolonged  effort  of  voluntary  repression 
of  his  displeasure-affects  toward  the  social  group  at  the 
club:  Symptoms  of  marked  mental  depression  were  pres- 
ent; the  patient  felt  great  resentment  toward  his  fellow- 
guests,  and  the  atmosphere  of  his  surroundings  became  un- 
bearable. He  felt  that  he  could  no  longer  associate  with 
his  present  companions,  and  desired  most  of  all  to  be  at 
home  with  his  family,  to  return  to  work,  and  to  live  the  life 
he  was  accustomed  to  living  before  he  came  under  the  pres- 
ent treatment.  This  feeling  had  been  entirely  absent  for 
some  time,  but  on  this  date  it  became  so  pronounced  that  he 
felt  as  if  he  could  not  stand  it  for  a  moment  longer.  He 
thought  that  being  free  from  attacks  for  a  longer  period 
than  ever  before  had  brought  about  so  much  improvement 
that  he  could  just  as  well  spend  his  time  at  home  rather 
than  in  the  company  of  people  he  was  not  interested  in  and 
in  an  environment  of  depression  and  lonesomeness. 

This  feeling  took  the  form  of  resentment  against  every- 
thing that  caused  him  to  be  kept  at  the  club.  Some  days 
previous  to  this  acute  condition  the  patient  had  a  dream  in 
which  the  doctor  wTas  keeping  him  in  bed  against  his  wishes; 
he  rebelled  against  this,  but  was  told  by  the  doctor  that  al- 
though he  might  feel  well  it  was  better  for  him  to  remain  in 
bed.     (Thus  he  put  the  doctor  in  the  wrong.) 

The  patient  knew  he  was  wrong  in  thinking  that  the  ex- 
isting conditions  were  not  the  best  for  him,  but  he  had  no 
power  to  stop  the  antagonistic  feeling  that  seemed  to  be  over- 
powering him.  He  felt  as  if  he  were  being  pressed  from  all 
sides,  and  everything  seemed  to  tighten  around  him.  To 
use  the  patient's  own  words:  "Even  the  skin  on  my  face, 
and  in  fact  upon  my  whole  body,  felt  tight;  my  mouth  was 
dry,  and  my  tongue  felt  rough  and  coated,  and  I  frequently 
found  myself  clutching  my  face  with  my  hands  in  a  nerv- 
ous manner.  I  lost  interest  in  my  surroundings  and  carried 
on  my  work  in  an  automatic  way,  having  only  the  one  de- 
sire, to  be  home  with  my  family.  I  found  the  greatest  relief 
and  comfort  in  being  alone  and  enjoying  my  own  company. ' ' 


88 

After  a  visit  to  the  physician  he  felt  better  and  this  feeling 
of  freedom  lasted  all  the  afternoon.  The  patient  joined  in 
work  with  the  others,  was  cheerful,  and  talked  pleasantly 
on  all  subjects  that  came  up,  and  never  once  referred  to  the 
depressed  feeling  so  marked  before  his  visit  to  the  physician. 
He  was  interested  in  his  various  duties  and  anxious  to  ac- 
complish more  than  usual.  However,  in  the  evening  while 
playing  bridge  the  depression  and  annoyance  seemed  to  re- 
turn, and  he  showed  keen  displeasure  at  the  plays  of  his 
companions  and  told  them  what  cards  they  should  have 
played. 

The  following  day  he  was  again  depressed;  this  feeling 
appeared  slowly  at  first  while  he  was  dressing,  but  as  he 
came  in  contact  with  the  different  tasks  of  the  day  and  was 
thrown  with  individuals  that  were  annoying  and  distasteful 
to  him,  it  increased  until  it  had  all  the  characteristics  which 
were  so  marked  the  day  before.  He  became  moody  and 
silent,  went  about  with  an  air  of  indifference,  and  answered 
in  monosyllables,  showing  no  desire  to  be  pleased  with  any- 
thing. When  in  the  company  of  those  whom  he  liked  he 
seemed  more  contented  and  talked  less  about  himself;  but 
manifested  his  displeasure  to  the  others  by  answering  quickly 
and  sharply,  and  plainly  showing  that  he  did  not  desire 
their  company.  These  symptoms  continued  throughout  the 
day,  the  routine  was  carried  out  indifferently  and  the  patient 
showed  no  real  interest  in  anything  but  a  strong  desire  to  be 
left  alone. 

On  the  third  day  of  the  depression  a  trip  to  W was 

planned,  to  which  the  patient  looked  forward  with  great 
pleasure  as  a  sort  of  deliverance  from  the  people  and  sur- 
roundings that  were  so  distasteful  to  him,  and  also  to  have 
the  society  of  the  guests  who  were  most  pleasing  to  him. 
The  depression  was  therefore  less  marked,  but  nevertheless 
present,  as  noted  by  the  sullen  expression  and  manner  in 
which  he  went  about  the  morning's  tasks.  In  the  afternoon 
the  trip  to  W was  made,  and  this  he  thoroughly  en- 
joyed. He  shopped  and  went  about  the  town  with  all  his 
old-time  happy  mood,  never  referring  to  the  depression  so 
noticeable  the  earlier  part  of  the  day.     He  returned  home 


89 

in  time  for  supper  and  was  agreeably  surprised  to  receive  a 
card  from  a  favorite  cousin  telling  him  that  he  would  receive 
a  visit  from  him  the  following  Sunday.  He  at  once  tele- 
phoned to  the  city  to  ascertain  the  time  the  cousin  would 
arrive,  and  made  arrangements  for  his  reception  at  the  club. 
This  was  done  in  an  excitable  manner  and  it  was  apparent 
he  was  in  a  state  of  suppressed  elation,  but  when  all  was 
completed  he  was  more  at  ease  and  felt  that  at  last  he  was 
to  have  some  "real  companionship."  He  retired  at  the 
usual  hour  and  slept  soundly  all  night. 

The  next  day,  Saturday,  the  patient  seemed  to  live  in 
anticipation  of  his  cousin's  visit,  and  showed  less  the 
symptoms  of  depression  that  were  hanging  over  him.  He 
attended  a  lecture  but  was  greatly  annoyed  at  the  actions 
of  some  of  the  guests,  and  remarked  that  it  was  a  shame 
people  of  intelligence  didn't  have  better  manners.  He  made 
no  reference  to  the  depression,  but  was  keyed  up  and  under 
tension.  In  the  evening  he  had  two  very  mild  psychic  at- 
tacks. On  going  to  bed  he  said  that  he  felt  better  and  knew 
he  was  foolish  to  be  so  depressed  over  conditions  that  were 
in  reality  not  at  all  as  he  saw  them.  It  was  very  apparent 
that  the  petit  mal  had  lessened  the  tension  to  a  marked 
degree. 

Sunday  was  spent  visiting  with  his  cousin,  and  the  patient 
appeared  cheerful  and  spent  the  morning  talking  about 
home,  former  companions  and  all  that  had  occurred  since 
he  had  left  home.  He  was  greatly  pleased  that  nothing  un- 
usual had  happened  during  his  absence,  and  that  after  all 
he  had  not  missed  so  much.  During  the  day  the  patient 
had  three  psychic  attacks  while  with  the  cousin,  which  were 
so  slight  in  character  that  no  one  but  himself  had  observed 
them.  In  the  afternoon  a  visit  to  a  fresh  air  home  proved 
a  great  success.  He  began  to  take  a  real  interest  in  every- 
thing and  to  appear  bright  and  cheerful  when  he  saw  all  the 
children  together  and  heard  them  sing.  He  was  greatly 
taken  with  the  parental  attitude  of  the  superintendent  and 
his  wife  and  the  manner  in  which  they  looked  after  the  chil- 
dren. His  heart  went  out  to  them,  and  when  they  cordially 
invited  all  to  return  again,  the  patient  was  more  than  en- 


90 

thusiastic  in  accepting.  He  returned  to  the  club  for  supper 
and  showed  no  signs  of  the  depression  that  had  been  pres- 
ent for  the  past  five  days.  He  was  cheerful  and  happy,  and 
talked  pleasantly  with  everyone  without  any  apparent  effort. 
He  states  that  he  feels  sure  the  slight  psychic  attacks  allowed 
him  to  give  in  more  and  to  realize  that  he  was  wrong;  be- 
fore the  attacks  occurred  he  knew  that  he  was  wrong,  but 
could  not  give  in.  The  attacks,  therefore,  played  an  im- 
portant part  in  relieving  the  tension.  He  remarked  that  he 
would  rather  have  the  attacks  and  get  relief  from  the  de- 
pression, because  they  were  over  within  a  short  time,  while 
the  depressed  feeling  would  have  to  last  for  a  long  time  if 
it  had  to  be  handled  naturally. 

Interest  in  things  that  were  pleasing  relieved  this  de- 
pressed state.  Companionship  of  those  who  were  of  a 
pleasing  type  helped  a  good  deal,  while  to  be  thrown  in  the 
company  of  those  who  were  distasteful  to  him  produced 
marked  annoyance  and  depression. 

The  foregoing  outline  of  a  mental  conflict  and  its  favor- 
able outcome  would  seem  to  be  something  as  follows:     On 

going  to  W the  patient  was  able  in  part  to  get  away 

from  the  disagreeable  situation  which  had  not  permitted  of 
solution;  going  to  town  and  shopping,  etc.,  improved  the 
condition  of  his  mental  outlook.  On  his  return  to  the  club 
and  getting  the  message  from  his  cousin  from  home  that  he 
would  make  the  patient  a  visit,  he  felt  more  of  the  displeas- 
ure modified.  Two  mornings  after,  the  actual  visit  with  his 
cousin  in  which  he  was  told  that  he  had  not  missed  much 
at  home,  that  many  of  the  things  he  was  interested  in  had 
not  been  much  changed  since  the  patient  left,  and  a  detailed 
account  of  how  his  father  and  mother  were  and  how  they 
had  spent  their  time  during  the  summer,  was  of  great  satis- 
faction to  him.  In  addition  to  that,  the  occurrence  of  three 
or  four  slight  attacks  (which  were  conscious  to  the  patient 
only  and  could  not  be  observed  by  the  others)  helped  to  dis- 
charge still  more  the  unconscious  demand  for  relief  from 
displeasure.  Then  the  afternoon  visit  to  the  fresh  air 
home  was  the  final  means  of  more  or  less  complete  release 
of  the  inner  tension.     There   he   saw  children   con  vales- 


91 

cing  from  various  diseases,  who  were  living  under  a  regime 
somewhat  comparable  to  his  own;  above  all  he  was  delighted 
with  the  superintendent  and  his  wife  who  were  in  charge  of 
the  place.  They  were  kindly  disposed,  rather  elderly  peo- 
ple, comparable  to  his  parents.  They  talked  with  him  in  a 
very  friendly  and  intimate  manner,  and  this  served  the  same 
purpose  of  the  deepest  release  as  making  a  visit  home  and 
seeing  his  own  parents.  Immediately  after  this  visit  the 
patient  returned  to  his  normal  condition,  without  having  a 
grand  mal  attack. 

Change  of  environment  is  often  a  disturbing  factor.  In 
the  next  setting  we  shall  see  what  influence  the  transfer  of 
the  club  back  to  its  winter  quarters  in  the  suburbs  had  on 
our  patient. 

With  the  departure  of  his  favorite  companions  he  at  once 
turned  his  attention  to  clearing  his  room  of  all  decorations, 
packing  his  trunks,  and  making  all  preparations  to  leave  at 
once.  As  the  date  he  was  to  leave  was  very  uncertain,  he 
became  restless  and  faultfinding  with  the  guests  still  in  the 
house.  Everything  went  wrong,  his  companions  were  irri- 
tating to  him,  and  they  had  nothing  in  common.  He  kept 
to  his  room  and  talked  continually  about  the  unpleasant- 
ness of  everything,  and  how  he  wished  he  could  leave.  It 
was  then  tactfully  suggested  by  his  nurse  that  it  might  be  a 
good  plan  to  visit  his  aunts  in  the  city  for  a  few  days  until 
his  new  quarters  were  ready.  This  at  once  met  with  his 
hearty  approval;  his  countenance  lit  up  and  he  became 
cheerful  and  happy.  He  could  not  get  away  quickly  enough, 
and  even  hired  an  auto  to  take  him  and  his  nurse  to  a  nearby 
town  so  that  an  earlier  train  could  be  taken  to  New  York. 
On  the  train  he  was  cheerful  and  talkative  about  everyday 
events  but  made  no  reference  to  the  place  he  had  just  left  or 
his  companions  that  had  been  his  favorite  topic  of  conver- 
sation all  summer.  On  the  other  hand,  he  frequently  spoke 
of  how  glad  he  was  going  to  be  to  see  his  aunts.  Arriving 
in  the  city  he  rushed  about  to  get  the  quickest  conveyance 
to  take  him  to  the  house,  and  on  reaching  there  he  kissed 
both  aunts  effusively  and  at  once  entered  into  a  long  account 
of  the  terrible  conditions  that  had  existed  all  summer.     The 


92 

aunts  listened  attentively,  but  showed  no  assent  to  his  views, 
and  he  gradually  became  less  demonstrative  toward  them. 
In  the  morning  he  announced  to  his  nurse  that  he  was  go- 
ing to  have  things  pleasant  and  comfortable  at  the  club 
during  the  winter,  that  he  was  "not  going  to  stand  for  any 
foolishness,"  and  if  things  were  not  just  right  he  would  go 
to  some  other  place;  if  the  doctor  did  not  approve  he  would 
go  home.  A  casual  visit  to  his  new  quarters  aggravated 
his  irritation;  he  found  the  house  still  upset,  the  room  not 
furnished,  and  everything  looked  gloomy,  the  day  being  wet 
and  foggy.  He  became  depressed  and  said  he  knew  every- 
thing was  going  to  be  unpleasant.  He  spoke  of  all  this  in 
an  excited  manner  to  his  aunts  on  his  return  to  the  city;  he 
even  became  demanding  in  his  desire  to  be  heard  and  to  ex- 
press fully  his  views.  He  again  took  up  the  subject  with 
the  nurse  next  morning,  and  the  following  plan  was  adopted: 
The  patient  was  asked  to  describe  all  that  was  pleasant  and 
all  that  was  unpleasant  about  the  new  environment  and  sur- 
roundings at  the  club,  and  to  give  his  candid  opinion  of 
everything  as  he  saw  it.  The  nurse  explained  that  this  was 
to  be  a  trial  balance  of  the  whole  difficulty,  to  find  out  just 
where  the  mistakes  were  and  to  devise  some  method  from 
the  result  so  that  everything  could  be  adjusted  properly. 
The  nurse  made  a  debit  and  credit  side  on  a  piece  of  paper. 
On  finishing  the  interview  it  was  shown  to  the  patient  that 
he  had  a  complete  debit.  He  was  asked  if  he  thought  this  to 
be  a  truthful  statement,  if  it  could  be  possible  for  every- 
thing to  be  as  wrong  as  he  had  pictured  it.  He  thought  for 
awhile  without  speaking;  then  tried  to  reply,  stammered  and 
blushed,  and  finally  got  up  from  his  chair  and  paced  the 
floor.  At  last  he  said:  "Well,  I  suppose — Oh,  I  know  I 
am  wrong,  but  I  can't  help  it,  because  it's  my  infernal  dis- 
position I  suppose;  that's  all  there  is  about  it."  The  nurse 
then  asked  if  the  patient  did  not  think  there  was  a  little  good 
in  everything,  that  some  redeeming  feature  might  be  found  in 
everything  if  one  only  took  the  trouble  to  look  for  it;  further, 
that  if  the  patient  would  only  assume  this  attitude  he  would 
get  more  real  pleasure  out  of  life,  as  it  was  only  by  looking  at 
the  bright  side  that  life  was  made  easier,  and  by  being  cheerful 


93 

and  making-  the  best  of  things  one  gradually  got  a  balance 
to  his  credit,  and  the  more  credit  one  obtained  of  this  sort 
the  better  one  would  be  guarded  against  the  little  trials  that 
came  up  in  daily  life.  During  this  explanation  the  patient 
lost  his  forceful,  determined  manner,  became  silent  and  sub- 
missive, and  agreed  with  the  nurse  in  everything.  He  said, 
however,  that  he  thought  normal  people  would  view  the  sit- 
uation in  the  same  light  as  he  did.  While  he  was  assured 
that  this  might  be  so,  it  was  pointed  out  that  his  attitude  to- 
ward the  facts  and  his  reactions  toward  them  were  unnatural 
and  harmful,  and  that  normal  individuals  did  not  allow  such 
trivial  matters  to  annoy  them  but  found  means  to  adjust  to 
all  conditions.  The  patient  then  became  more  cheerful  and 
promised  to  make  an  effort  to  do  his  part  in  being  agreeable. 
He  did  not  again  refer  to  the  conversation  but  on  returning 
to  the  new  quarters  he  showed  his  willingness  to  cooperate 
with  the  nurse  and  physician.  He  was  pleasant  and  cheer- 
ful with  his  companions  and  became  occupied  in  arranging 
his  room  and  putting  everything  in  order.  He  became  en- 
thusiastic over  golf  and  tennis,  his  wood  carving,  and  his 
music  and  took  up  his  daily  routine  in  a  manly  fashion. 

A  rather  unusual  outcome  of  such  a  conversation  is  shown 
in  the  patient's  insight  by  his  remark  that  he  "feels  such 
talks  with  the  physician  and  nurse  are  just  what  he  needs 
and  that  he  derives  great  benefit  from  them. ' '  He  says  they 
"straighten  him  out  and  put  him  on  the  right  road  again." 
He  shows  an  appreciation  of  how  fundamental  the  defect  in 
his  character  is,  in  an  after-statement  that  he  feels  as  if  he 
would  never  get  into  such  a  fussed  up  state  again  when 
anything  appeared  to  be  so  depressing  and  disagreeable. 

I  may  say,  however,  lest  one  may  think  such  lines  of 
treatment  are  final  and  conclusive,  within  three  or  four  days 
our  patient  had  typical  resistive  dreams,  which  in  turn  ex- 
pressed themselves  or  inflated  the  deeper  unconscious  to 
bring  about  a  discharge  in  a  series  of  psychic  attacks  and 
one  grand  mal  attack  a  week  after  the  close  of  the  above 
incident.  But  the  whole  epileptic  reaction  was  much  less 
severe  and  disabling  than  any  other  for  several  months  past. 

It  is  important  to  note  the  disastrous  effects  in  the  reverse 


94 

of  gentle  wise  training-treatment  in  such  individuals  as  our 
patient.  Through  a  peculiar  misunderstanding  the  nurse 
drove ' '  our  patient  for  two  days  at  rather  top  speed  in 
every  way,  almost  duplicating  the  type  of  bad  care  and  in- 
attention such  supersensitive  individuals  receive  before  their 
first  attack  of  epilepsy.  The  enforced  plan  of  daily  routine 
chanced  upon  a  Sunday,  on  which  day  it  had  been  custom- 
ary for  the  patient  to  rest  and  take  it  easy.  As  usual  on 
this  morning,  he  made  preparations  to  remain  in  his  room, 
to  read  the  papers  and  write  letters.  At  this  juncture  he 
was  called  upon  to  take  a  long  walk  with  other  guests  at  the 
club,  and  he  hurried  to  finish  the  letter  he  was  writing. 
The  pace  on  the  walk  was  extra  severe,  and  he  was  rushed 
along  mile  after  mile.  He  managed  to  keep  up  pretty  well 
after  the  first  mile,  and  although  he  tried  to  appear  cheerful 
he  began  to  grow  rather  silent  in  conversation  and  worried 
lest  they  might  be  late  for  dinner.  They  covered  about 
seven  miles,  and,  as  the  patient  predicted,  they  were  late  for 
dinner.  He  had  a  ravenous  appetite  after  the  walk,  but 
was  not  allowed  to  satisfy  it  by  extra  helpings  as  usual. 
He  looked  disappointed,  but  submitted  in  silence,  and  went 
to  his  room  to  write  his  belated  correspondence  and  read  the 
morning  papers.  He  spent  but  an  hour  or  so  in  this  easy 
atmosphere,  when  he  was  asked  to  go  for  another  little  walk. 
He  now  began  to  complain,  saying  he  felt  tired  and  had 
other  things  to  do.  He  finally  submitted  with  apparent  re- 
luctance and  walked  four  miles  more.  Although  he  was 
neither  sullen  nor  displeased,  it  was  seen  that  his  good  feel- 
ings were  "wearing  thin."  He  now  remained  quiet  and 
started  no  new  subjects  of  conversation  and  evinced  no  in- 
terest in  the  topics  brought  up  by  the  nurse.  Nothing 
unusual  happened  during  the  evening,  as  he  was  allowed  to 
do  just  as  he  pleased.  His  various  remarks  and  comments 
were  disputed  but  he  showed  little  annoyance  at  such  criti- 
cism. He  went  to  bed  and  slept  well.  The  next  morning 
he  was  inclined  to  be  uncommunicative,  his  replies  were 
brief  and  it  was  quite  evident  that  he  did  not  wish  to  talk. 
His  face  was  a  trifle  pale  and  drawn,  and  he  appeared  pre- 
occupied.    He  soon  showed  that  he  wanted  to  be  left  alone, 


95 

and  that  he  wished  to  initiate  the  usual  routine  of  daily 
duties  himself.  He  began  to  question  the  nurse's  sugges- 
tions and  wanted  various  plans  of  work  modified.  He  said: 
I  feel  as  though  I  want  things  to  go  along  smoothly  to- 
day, and  I'd  rather  this  scheme  be  followed  rather  than  what 
you  (the  nurse)  have  planned."  When  asked  if  he  was 
not  feeling  well,  he  appeared  annoyed  and  offended,  and 
answered  quickly:  "Why,  yes;  I'm  all  right,"  which 
statement,  however,  was  belied  by  his  manner  and  facial 
expression.  He  then  went  about  his  duties  silently  and  with 
downcast  appearance.  He  sat  at  his  desk  until  breakfast, 
which  was  unusual  as  he  most  frequently  dresses  quickly 
after  his  morning  plunge  and  goes  about  singing  and  whist- 
ling, and  joshing  the  other  guests  who  are  behind  in  getting 
up.  He  usually  hurries  downstairs,  gets  the  morning  paper 
and  seeks  the  society  of  his  favorite  guest  or  takes  a  walk 
outside  to  see  what  the  weather  promises  for  engaging  in 
sports.  After  breakfast  he  was  not  allowed  the  usual  little 
rest  but  was  rushed  out  on  a  mission  several  miles  away. 
He  was  required  to  carry  bundles  and  a  series  of  ques- 
tions were  fired  rapidly  at  him,  put  to  him  in  such  a 
manner  that  he  was  required  to  answer.  His  opinion  was 
asked,  and  then  disputed.  He  felt  as  though  "  he  was  be- 
ing kept  on  edge  "  all  the  time,  and  felt  pushed  at  a  physical 
and  mental  pace  to  which  he  was  unaccustomed.  However, 
he  stood  all  this  fairly  well,  although  he  showed  more  desire 
to  be  let  alone  but  without  being  moody  or  depressed.  When 
allowed  to  stop  for  some  music  records  and  do  as  he  liked 
for  an  hour  he  brightened  up  and  seemed  momentarily  happy, 
but  so  soon  as  the  lesson  questioning  was  begun  again  on 
the  way  home  and  the  pace  grew  quicker  he  fell  altogether 
silent  and  sullen,  and  spoke  only  when  absolutely  necessary. 
Arriving  home  he  at  once  lay  on  his  bed  and  busied  himself 
with  his  home  paper.  While  he  had  not  openly  revolted  at 
the  treatment,  he  indicated  by  his  attitude  that  the  whole 
plan  was  not  to  his  liking.  Physically  he  showed  his  ability 
to  stand  even  more  forced  exercising,  but  he  began  to  show 
that  it  all  interfered  with  his  peace  of  mind.  Now  he  be- 
gan to  be  more  listless,  pale,  and  lapsed  into  a  sullen  and 


96 

morose  state  in  which  he  seemed  "to  withdraw  from  his  en- 
vironment "  and  lapsed  into  long  periods  of  deep  thought. 
After  his  dinner  he  was  sent  with  some  of  the  guests  he  did 
not  particularly  like  to  a  vaudeville  performance.  On  his 
return  he  expressed  his  displeasure  at  being  ' '  forced  to  go 
to  such  a  show  in  such  company."  It  was  apparent  sev- 
eral times  that  he  had  other  deeper  objections  to  offer  but 
which  he  fairly  repressed.  He  spent  the  remainder  of  the 
afternoon  by  himself  reading  and  writing  letters.  After 
supper  he  was  a  little  more  cheerful  but  was  not  his  usual 
self.  He  was  most  at  ease  in  his  room  alone.  The  next 
morning,  the  third  day  of  enforced  routine,  he  was  plainly 
in  his  old  mood  of  dissatisfaction  and  moroseness;  in  his 
words:  he  "felt  sore  and  didn't  have  a  'good  morning'  for 
anyone."  He  showed  great  inclination  to  omit  the  morn- 
ing exercises.  He  went  about  his  daily  task  slowly  and  in 
a  negligent,  disinterested  manner,  speaking  only  when  di- 
rectly addressed.  He  had  a  sullen  expression  and  answered 
sharply  and  in  monosyllables.  It  was  plainly  apparent  that 
he  was  on  the  verge  of  a  "wave  series,"  and  a  halt  in  the 
enforced  draught ' '  treatment  was  made.  He  was  allowed 
his  own  time  to  do  his  different  duties.  Still  he  showed  that 
he  thought  everything  was  wrong.  He  was  annoyed  be- 
cause "certain  letters"  didn't  come;  then,  too,  he  would 
not  join  the  golf  club  if  he  didn't  hear  that  very  day  of  his 
election.  His  expression  was  dull,  eyes  starey,  and  face 
pale.  Tennis,  his  favorite  sport,  was  suggested,  but  there 
was  something  wrong  there;  then  a  final  straw  was  a  sug- 
gestion to  saw  and  chop  wood.  He  at  once  asked  in  a 
pleading  tone  if  he  might  wood-carve.  Everything  was 
made  ready  for  the  carving.  The  nurse  helped  him  with 
the  more  difficult  part  of  the  work,  the  carving  was  has- 
tened along  and  finished,  and  the  tray  which  they  perfected 
was  sent  as  a  present  to  one  of  the  patient's  friends.  At 
first  the  work  was  begun  in  silence,  but  as  it  advanced  he 
began  to  regain  his  spirits.  He  volunteered  the  informa- 
tion that  somehow  he  felt  better,  a  load  was  taken  off, 
etc.  But  the  latent  feeling  of  irritation  had  been  stirred 
too  deeply  to  be  gotten   rid   of   at   once.     At   the   dinner 


97 

table  he  made  a  few  cutting  remarks,  but  seemed  to 
gain  added  spirits  as  he  did  so,  especially  when  he 
received  no  "scratch"  in  the  fray.  He  then  became  a 
bit  elated,  jocose  and  boyish  in  spirits.  He  attended  a 
football  game  in  the  afternoon  and  remarked  that  he  was 
getting  his  balance  again  and  that  he  had  felt  a  growing  dis- 
like toward  everyone  and  everything,  a  sort  of  disgust  in 
his  stomach,  but  it  was  now  passing  away.  However,  the 
great  depth  to  which  the  irritation  had  penetrated  still  pre- 
saged itself  in  the  night  dreams.  He  dreamed  he  was 
wood-carving  (favorite  craft)  and  that  he  was  conscious  he 
was  going  to  have  an  attack.  The  nurse  was  out  of  the 
room  (a  personal  objection  to  the  latter 's  attitude  of  the  past 
two  days)  and  when  another  (unfriendly)  guest  sought  to 
call  the  nurse  our  patient  showed  anger  and  said:  "You 
fool,  I'm  all  right;  I've  gotten  rid  of  it."  The  attacks  are 
always  used  in  the  dream  in  their  proper  psychologic  sense 
(to  get  rid  of  unpleasant  things). 

The  next  day  our  patient  said,  "I  can't  understand  why 
that  old  feeling  came  up  in  my  stomach  for  the  past  two 
or  three  days;  I  think  it  must  have  been  on  account  of  the 
weather,  or  something  not  going  right  outside  my  recollec- 
tion now  " — a  bit  of  false  rationalization  common  enough 
in  the  study  of  causes  in  normal  individuals,  to  say  noth- 
ing of  a  similar  reasoning  in  the  pathogenesis  of  epilepsy 
itself.  It  may  be  added  that  no  attacks  were  incipient  at 
this  time  and  no  attacks  occurred  for  over  10  days  after  the 
above  notes,  nor  has  our  patient  been  depressed  or  sad. 

Even  though  for  all  ordinary  routine  affairs  he  has  learned 
to  adapt  himself  fairly  well,  the  old  irreconcilable  attitude 
to  uncongenial  changes  has  not  been  fully  met.  While  he 
may  be  rescued  from  ordinary  epileptic  reactions,  such  as 
epileptic  attacks,  long  after  these  he  will  have  minor  con- 
tests that  may  be  below  the  level  of  the  demand  for  a  fit  re- 
action of  the  grand  neurosis. 

From  the  sketched  outline  of  the  foregoing  case  it  is  ob- 
vious that  our  patient  has  relatively  the  same  inherent  epi- 
leptic make-up  as  the  mother — the  inability  to  develop  out 
of  the  infantile  emotional  life  of  the  narcissistic  period,  ego- 


98 

tistic  and  supersensitive  as  it  is  shown  to  be.  Further  in- 
fringements of  outside  demands  make  such  an  individual 
break  into  tantrums,  employ  day  dreams,  later  violent 
tempers  and  mental  abstractions,  and  finally  as  the  puberty 
and  adult  demands  appear,  one  sees  the  epileptic  reaction 
supervene  with  its  well-known  setting  and  peculiar  mech- 
anism. 

It  is  interesting  to  note  what  the  sister's  reactions  are, 
endowed  as  she  is  with  a  somewhat  similar  make-up  to  that 
of  the  brother.  (See  No.  3  on  chart.)  She  also  has  the 
same  kind  of  temperament  and  "can  not  bear  disappoint- 
ment." She  is  rather  quick  tempered,  but  has  it  more 
under  control ;  as  the  disappointments  or  anger  situations 
occur  she  feels  keyed  up  inside  and  her  knees  begin  to 
shake,  and  then  she  "  undergoes  a  state  of  agony  that  other 
people  can't  realize."  She  gets  square  with  things  by 
letting  the  conflicts  wear  off,  but  there  is  always  a  feeling 
of  resentment.  She  is  very  sensitive  to  her  surroundings, 
and  states  that  she  can  tell  immediately  when  a  person  is 
not  in  good  humor  without  looking  at  him.  As  a  young  girl 
music  helped  a  good  deal,  especially  when  lonely  or  miser- 
able. She  now  has  a  sympathetic  husband  who  carries 
her  over  many  difficulties;  she  has  two  children,  the  older 
one  very  much  resembling  herself.  She  says,  "  My  mother 
is  a  dear,  sweet  woman,  but  it  never  occurred  to  her  to  try 
to  understand  her  children,  but  to  make  them  what  she 
thought  they  ought  to  be.  My  father  is  different,  and 
reason  is  one  of  his  uppermost  ideas;  when  he  said  'No' 
he  meant  it.  But  with  my  mother  there  wasn't  any  sym- 
pathy or  understanding;  I  miss  it  very  much  and  have 
always  regretted  this  lack  of  sympathy  very  keenly." 

The  sister  met  similar  situations  at  home  that  the  brother 
did;  she  frequently  had  a  sense  of  being  balked,  but  never 
went  into  a  rage  of  the  tantrum  type.  She  argued  a  great 
deal  more;  and  though  she  bore  a  great  deal  of  resentment 
at  times,  she  would  argue  and  generally  end  the  conflict  in 
weeping  if  she  could  not  get  her  way.  She  would  fight  it 
down  or  go  to  her  room  and  cry  it  off.  Once  she  wept  a 
whole  day,  but  when  the  parents  would  not  give  in  and  she 


99 

found  she  was  the  only  one  suffering  and  no  one  bothered 
about  her,  that  she  was  simply  working  herself  up  for  noth- 
ing, she  gave  in.  She  realized  that  in  opposing  her  mother 
it  was  like  "ramming  against  a  stone  wall."  A  great 
advantage  in  her  handling  these  episodes  was  that  she 
went  forward  to  find  some  way  out,  to  seek  some  solution 
that  was  endurable,  as  it  were.  She  felt  that  she  could  not 
reason  with  her  mother,  and  if  she  wanted  anything  granted 
she  always  went  to  the  father  and  found  it  a  great  satisfac- 
tion to  talk  it  out  with  him,  even  though  she  could  not  get 
her  way.  He  would  present  the  facts,  and  would  then  give 
her  the  privilege  to  decide;  this,  of  course,  was  not  the 
mother's  method  at  all.  The  brother's  conflicts  were  never 
adjusted  this  way,  because  he  never  went  to  the  father. 

While  the  spinal  curvature  might  have  been  bad  for  her 
physical  welfare,  it  certainly  won  for  her  some  distinct  res- 
pite from  the  mother's  rigid  moral  discipline  and  she  was 
soon  sent  away  to  a  congenial  environment  in  a  sisters' 
school  in  a  distant  city.  In  regard  to  the  slight  permanent 
curvature  not  noticeable  at  present,  she  says,  ' '  Perhaps  I 
am  keenly  sensitive  because  the  curvature  has  been  the 
greatest  burden  I  could  ever  imagine — to  be  what  I  should 
not  have  been.  For  years  I  could  not  bear  to  go  without  a 
coat.  I  wanted  to  be  a  nun,  and  thought  their  lives  ran  so 
smoothly.  Then  I  realized  that  the  perfection  they  had 
reached  was  not  'real'  life." 

Regarding  her  little  son  (No.  6),  three  years  old,  who  re- 
sembles her  in  physical  and  mental  make-up,  but  who 
possesses  characteristics  identical  to  those  of  her  brother 
(No.  4),  she  says:  "Occasionally  my  little  boy  sits  and 
dreams;  whether  he  does  it  consciously  I  don't  know;  when 
we  try  to  get  him  back  to  reality  he  refuses  to  be  aroused  for  a 
while.  He  isn't  restless,  but  sometimes,  such  as  waiting 
for  lunch,  he  just  sits  and  dreams.  I  have  been  very  care- 
ful with  him;  I  don't  want  to  stir  him  up  to  any  great  men- 
tal force  and  don't  like  to  clash  wills  at  all.  I  have  never 
tried  to  break  his  will  and  have  never  spanked  him.  I  had 
a  nurse  last  year  of  whom  he  was  very  fond;  one  time  she 
tapped  his  fingers  for  doing  some  little  thing,  and  it  nearly 


100 

broke  his  heart.  If  I  speak  at  all  firmly  to  him  he  will 
look  up  and  say,  'You  love  me,  mother,  don't  you?'  and 
if  not  assured  that  I  do,  he  will  be  all  cut  up  over  it  and 
cry.  He  loves  to  play  with  his  dolls  and  is  happy  for  hours 
with  them.  Both  of  my  children  talk  to  their  dolls  and 
pet  them,  and  never  spank  them."  The  boy  often  gets 
into  a  mental  attitude  which  indicates  he  is  about  ready 
for  a  tantrum  and  says  "I  won't,"  then  stiffens  up,  and 
"one  word  more"  would  drive  him  into  a  "physical  as 
well  as  a  moral  cramp."  Then  he  is  taken  by  himself  and 
a  kindly  talking  to  smoothes  out  the  whole  situation.  The 
mother  wisely  says,  "it  is  simply  a  matter  of  getting  him 
to  unfold  his  rigid  will,  and  meeting  the  situation  with 
gentleness  is  the  only  way  to  get  around  these  episodes." 

To  summarize,  we  have  here  the  grandmother  with  the 
epileptic  character  and  reaction ;  the  son  with  the  same,  the 
daughter  with  the  make-up  in  greater  part  but  with  enough 
of  the  paternal  characteristics  and  proper  training  under 
the  father's  guidance,  together  with  a  prolonged  training 
away  from  home,  to  enable  her  to  adjust  herself  to  the  var- 
ious vicissitudes  of  "irritating  reality"  without  epileptic 
reactions.  A  grandson  with  the  apparently  identical  make- 
up his  uncle  possesses,  is  being  trained  wisely  and  sanely 
by  his  mother,  and  it  would  seem  as  though  he  stands  a 
fair  chance  to  avoid  an  epileptic  reaction  in  later  life. 


101 


Section  IV. 

METHOD     OF    GRAPHICALLY     RECORDING     THE     MENTAL 
FACTORS    PRECIPITATING  EPILEPTIC  REACTIONS. 

In  the  psychological  study  of  the  frank  idiopathic  epilep- 
sies the  question  often  arises,  why  may  not  one  more  or  less 
definitely  predict  the  occurrence  of  seizures  in  the  individual 
case,  especially  when  definite  upsetting-  mental  factors  are 
in  evidence? 

Even  if  one  were  able  to  exclude  the  many  inciters  to 
attacks  arising  on  a  physical  basis,  such  as  are  notably  seen 
in  constipated  epileptics,  the  problem  would  still  be  far  from 
a  satisfactory  solution.  First,  because  the  real  motivation 
of  the  fit  is  frequently  unconscious,  even  though  an  obvious, 
external  and  conscious  cause  of  stress  and  irritation  be  at 
hand.  Often  a  more  or  less  definite  upsetting  episode, 
seemingly  harmless  in  itself,  produces  or  is  followed  by  an 
attack,  and  frequently  a  trying  situation  is  not  followed  by 
an  attack.  However  true  this  may  be,  the  fact  still 
remains  that  a  trained  observer  can  tell  rather  definitely 
when  an  epileptic  is  about  to  have  some  sort  of  seizure 
reaction.  These  observations  have  not  been  handled  with 
the  degree  of  careful  study  the  subject  would  seem  to 
warrant.  If  there  is  a  dynamic  element  in  the  modification 
of  the  daily  routine  of  the  epileptic  that  tends  to  produce 
or  inhibit  seizures,  our  subject  may  be  of  prime  therapeutic 
importance.  The  attacks  would  then  be  viewed  as  a  result 
of  the  degree  and  amount  of  mental  perturbation  which 
the  individual  epileptic  can  not  ordinarily  handle  in  a 
healthy  manner.  Obviously  there  are  so  many  physical  as 
well  as  psychical  factors  to  be  reckoned  with  in  the  indi- 
vidual epileptic's  life  that  we  can  outline  only  in  most 
general  terms  the  relationship  between  upsetting  types  of 
stress  and  their  sequential  epileptic  reactions.     To  compli- 


102 


cate  further  the  task,  the  epileptic  himself  varies  consider- 
ably from  day  to  day  in  his  ability  to  handle  his  difficulties. 
However,  for  some  time  in  the  past  not  a  few  observers 
have  striven  to  record  a  parallelism  between  certain  toxic 
states  and  epileptic  fits. 

I  have  thought  it  not  unprofitable  to  chart  some  of  the 
mental  states  in  their  relationship  to  the  epileptic  reactions. 
The  charts  are  self-explanatory.  It  has  been  observed,  when 
the  patient  is  living  in  a  mental  state  in  which  he  manu- 
factures his  own  interests,  he  is  happy  and  contented  and 
least  likely  to  show  epileptic  reactions.  When  he  is  acting 
under  the  direction  of  a  trainer  and  must  be  encouraged 
daily  at  his  work  and  ordinary  routine,  he  is  more  likely  to 
have  attacks.  So  soon  as  neither  condition  exists,  he  often 
falls  into  states  of  lethargy  or  day-dreaming,  and  when 
aroused  may  be  irritable  and  angry,  or  sullen  and  illy  dis- 
posed, and  then  attacks  are  not  far  distant.  States  of 
elation  also  have  a  significance  in  relation  to  attacks. 

The  charts  are  taken  from  actual  daily  observation;  all 
these  cases  are  under  my  personal  supervision,  and  so  far 
as  possible  the  existence  of  physical  factors  has  been  ruled 
out. 

Chart  No.  I. 


CHARTo 

fEI 

>ll 

EP 

TIC  REACTSOh 

"S 

for  Month  of 

Har, 

916. 

I 

2 

3 

4 

5  € 

>  7 

3 

9  ! 

0  II 

\2 

S3 

[4 

15 

16 

17 

18, 

19 

20 

21  2 

2  23  24 

25  26 

27 

28 

29 

30 

31 

6RANDMAL 

$ ! 

Petit  Mal 

*■  i 

a 

Phenomena 

1 

| 

\\\ 

[ 

I8 

ElATION 

'1 

i 

Anger 

1 

Irritation 

II 

II 

II 

II 

III 

ll 

1 

1 

I 

1 

1 

IETHAR6Y 

II 

II 

mi 

III 

: 

1 

1 

f-j 

I 

i 

i  y 

Interest 

1 

1! 

II 

■1  II  II  II  II II  II  II  Ml  II 

spontaneous 
Interest 

4- 

1 

_i 

1 

U 

1 

■1  M  -1-U-l- 1  1  1  '[■ 

1 

1 

1 

1 

i\ 

Chart  I.  Beginning  March  1st,  the  patient's  interest  in 
the  routine  had  to  be  directed;  he  preferred  to  sit  in  his 
room  and  read,  becoming  irritable  when  certain  orders  were 
insisted  upon.  This  condition  lasted  up  to  the  4th.  On 
the  evening  of  the  4th  he  received  a  message  from  a  favorite 
cousin  telling  him  he  would  spend  the  following  day  with 
him.     The  patient  went  to  bed  in  a  very  happy  frame  of 


103 

mind.  On  getting-  up  the  next  day  he  was  cheerful  and 
remarked  frequently  that  he  was  glad  he  was  going  to  see 
"someone  from  home."  The  cousin  arrived,  and  the 
patient  at  once  took  the  initiative ;  he  showed  the  cousin 
about  the  grounds,  made  arrangements  for  dinner,  played 
the  piano  for  him,  and  spent  a  very  pleasant  day.  The 
next  day,  however,  he  was  moody,  and  pouted  when  told 
to  hurry  along  with  the  morning  work.  During  the  day  he 
had  two  mild  psychic  waves.  On  the  7th  it  was  necessary 
to  direct  him  to  follow  out  his  daily  tasks.  He  showed  a 
desire  to  sit  and  dream,  and  became  irritable  when  told  he 
had  certain  duties  to  perform.  The  8th  showed  a  condition 
that  still  required  direction,  but  no  lethargy  or  irritation 
resulted.  On  the  9th  and  10th  mild  psychic  waves  were 
noted,  probably  due  to  the  suppression  of  the  irritations 
some  days  previous.  From  the  11th  to  the  15th  there  was 
an  entire  change  in  the  patient's  disposition.  He  was 
cheerful,  happy  and  contented;  his  interest  was  spontane- 
ous, and  he  produced  good  work.  From  the  16th  to  the 
20th  a  condition  of  marked  irritability  was  present. 
Nothing  seemed  "just  right."  He  did  not  want  to  follow 
out  even  the  simplest  directions,  preferring  to  be  left  alone 
in  his  room  where  he  spent  his  time  trying  to  read  although 
he  could  not  concentrate;  he  sat  and  stared  as  if  dreaming 
or  in  deep  thought,  and  was  irritated  by  being  told  it  would 
be  best  for  him  to  try  to  follow  out  the  regular  order  of 
routine.  On  the  21st  and  22nd  complete  attacks  were 
noted.  On  the  23rd  he  felt  greatly  relieved  but  could  not 
"  get  started, "  as  he  put  it.  He  was  allowed  to  rest  all 
that  day.  On  the  24th  and  25th  he  had  mild  psychic  attacks. 
This  apparently  relieved  the  patient  completely,  for  he  at 
once  took  hold  of  things  of  his  own  accord,  as  he  had  so 
noticeably  done  on  the  11th,  and  for  more  than  a  week  his 
interest  was  spontaneous  and  he  showed  a  rapid  improve- 
ment in  all  his  work. 


104 
Chart  No.  II. 


157  DAY 

2*P  DAY 

35?  DAY 

A,n 

II 

A.M. 

3 

P.M 

5 

P.M. 

9 

P.M. 

7 

A.M. 

b>30 
AM 

ii 

AM. 

||30 

AM. 

5 

P.M. 

5 

P.M. 

IT 

AM 

9    IO 

AM.  AH 

1130 

AH 

• 

1230 

P-M 

RM 

z 

RM 

GRAND  PtAL 

PETIT  MAL 

PSYCHIC 
PHENOMENA 

ELATION 

ANGER 

l 

IRRITATION 

II 
III 

i  \m 

1 

| 

N 

1 

LETHARGY 

llll  1 

II 
II 

mill  hi 

II 
II 

DIRECTED 
INTEREST 

III  II II  III 

1  HI  II II II  1 

III  III 

SPONTANEOUS 
INTEREST 

1    1    1 

11         1         II         1        1        II        II 

ll 

Chart  II.  It  is  important  to  note  the  disastrous  effects 
of  the  reverse  of  gentle  and  wise  training  treatment  in  pro- 
ducing the  type  of  emotional  disturbances  which  are 
frequently  seen  preceding  attacks. 

Through  a  peculiar  misunderstanding,  the  nurse  "drove  " 
this  patient  for  two  days  at  rather  top  speed.  The  enforced 
routine  chanced  upon  a  Sunday,  on  which  day  it  had  been 
customary  for  the  patient  to  rest  and  take  his  ease.  As 
usual,  on  this  morning,  he  made  preparations  to  remain  in 
his  room,  to  read  the  papers  and  write  letters.  At  this  junc- 
ture he  was  called  upon  to  take  a  long  walk,  and  he  hurried 
to  finish  the  letter  he  was  writing.  The  pace  on  the  walk 
was  unusually  severe,  he  was  rushed  along  mile  after  mile, 
but  managed  to  keep  up  pretty  well.  Although  he  tried  to 
appear  cheerful,  he  began  to  grow  rather  silent,  and  worried 
lest  they  might  be  late  for  dinner.  They  covered  about  seven 
miles,  and,  as  the  patient  had  predicted,  they  were  late  for 
dinner.  He  had  a  ravenous  appetite  but  was  not  allowed  to 
satisfy  it  by  the  usual  extra  helpings.  He  looked  disap- 
pointed but  submitted  in  silence,  and  went  to  his  room  to 
attend  to  his  belated  correspondence  and  read  the  papers. 
He  spent  but  an  hour  in  this  easy  atmosphere  when  he  was 
asked  to  go  for  another  walk.  He  now  began  to  complain, 
saying  he  felt  tired  and  had  other  things  to  do.  He  finally 
submitted  with  obvious  reluctance,  and  walked  four  miles 


105 

more.  Although  he  was  neither  sullen  nor  displeased,  it  was 
seen  that  his  good  humor  was  "  wearing  thin."  He  now  re- 
mained quiet,  started  no  new  subjects  of  conversation,  and 
evinced  no  interest  in  the  topics  brought  up  by  his  compan- 
ions. Nothing  unusual  occurred  during  the  evening  as  he 
was  allowed  to  do  just  as  he  pleased.  Although  his  various 
comments  and  remarks  were  disputed,  he  showed  little 
annoyance  at  such  criticism.  He  went  to  bed  and  slept 
well.  The  next  morning  he  was  uncommunicative;  his  re- 
plies were  brief  and  it  was  quite  evident  that  he  did  not  wish 
to  talk.  His  face  was  pale  and  drawn,  and  he  appeared 
preoccupied.  He  soon  showed  that  he  wanted  to  be  left 
alone,  and  that  he  wished  to  initiate  the  usual  daily  duties 
himself.  He  began  to  question  the  nurse's  suggestions  and 
wanted  various  plans  of  work  modified,  saying:  "  I  feel  as 
though  I  want  things  to  go  along  smoothly  to-day,  and  I'd 
rather  we  should  do  this  than  what  you  have  planned." 
When  asked  if  he  were  not  feeling  well,  he  appeared  an- 
noyed and  offended,  and  answered  quickly:  "Why,  yes; 
I'm  all  right."  His  statement,  however,  was  belied  by  his 
manner  and  expression.  He  went  about  his  duties  silently 
and  with  downcast  appearance.  He  sat  at  his  desk  until 
breakfast,  which  was  unusual  as  he  most  frequently  dresses 
quickly  after  his  morning  plunge,  goes  about  singing  and 
whistling,  and  "joshes"  the  other  guests  who  are  late  in  get- 
ting up.  After  breakfast  he  was  not  allowed  the  usual  little 
rest  but  was  rushed  out  on  a  mission  several  miles  away. 
He  had  to  carry  bundles,  and  questions  were  fired  rapidly  at 
him,  put  in  such  a  manner  that  he  was  required  to  answer. 
His  opinion  was  asked,  and  then  disputed.  He  felt  as  if 
he  were  being  "kept  on  edge"  all  the  time,  and  pushed  at 
a  physical  and  mental  pace  to  which  he  was  unaccustomed. 
However,  he  stood  all  this  fairly  well,  showing  more  desire 
to  be  let  alone  than  moodiness  or  depression.  Arriving 
home,  he  at  once  lay  down  on  his  bed  and  busied  himself 
with  his  home  paper.  While  he  had  not  openly  revolted  at 
the  treatment,  he  indicated  by  his  attitude  that  the  whole 
plan  was  not  to  his  liking  and  interfered  with  his  peace  of 
mind.     He  began  to  be  more  listless  and  pale,  lapsing  into 


106 

a  sullen,  morose  state  in  which  he  seemed  to  "withdraw 
from  his  environment,  "  and  indulging  in  long  periods  of  deep 
thought.  After  his  dinner  he  was  sent  with  some  guests  he 
did  not  particularly  like  to  a  vaudeville  performance  and 
expressed  his  displeasure  at  being  ' '  forced  to  go  in  such  com- 
pany . ' '  After  supper  he  was  a  little  more  cheerful  although 
not  his  usual  self.  Next  morning,  the  third  day  of  his 
enforced  routine,  he  was  plainly  in  his  old  mood  of  dissatis- 
faction and  moroseness;  in  his  words,  he  "felt  sore  and 
didn  't  have  a  '  good  morning  '  for  anyone. "  He  went  about 
his  daily  tasks  in  a  negligent,  disinterested  manner,  speak- 
ing only  when  directly  addressed.  He  had  a  sullen 
expression  and  answered  sharply.  It  was  plainly  apparent 
that  he  was  on  the  verge  of  a  "wave"  series.  A  halt  in 
the  enforced  routine  was  made,  and  he  was  allowed  his  own 
time  to  do  his  various  duties.  Still  he  showed  that  he 
thought  everything  was  wrong.  His  expression  was  dull, 
his  eyes  starey,  and  face  pale.  Tennis,  his  favorite  sport, 
was  suggested,  but  something  was  wrong  there;  then 
the  final  straw  was  a  suggestion  to  saw  wood.  He  at  once 
asked  in  a  pleading  tone  if  he  might  wood-carve.  Every- 
thing was  made  ready  for  the  carving,  the  nurse  helped  him 
with  the  more  difficult  part  of  the  work,  and  the  carving  of 
a  tray  was  hastened  along  and  finished.  This  the  patient 
sent  off  immediately  to  one  of  his  friends.  He  then  showed 
signs  of  regaining  his  spirits,  and  volunteered  that  somehow 
he  felt  better,  a  load  was  taken  off  his  mind,  etc.  The 
latent  feeling  of  irritation  had  been  stirred  too  deeply,  how- 
ever, to  be  gotten  rid  of  at  once.  At  the  dinner  table  he 
made  a  few  cutting  remarks,  but  seemed  to  gain  added 
spirits  when  he  received  no  ' '  scratch  ' '  in  the  fray .  However, 
the  great  depth  to  which  the  irritation  had  penetrated  still 
showed  itself  in  the  night  dreams.  He  dreamed  he  was 
wood-carving  and  that  he  was  conscious  he  was  going  to 
have  an  attack.  When  the  nurse  was  out  of  the  room  (a 
representation  of  his  objection  to  the  latter's  attitude  of  the 
past  two  days)  and  another  (unfriendly)  guest  sought  to 
call  the  nurse,  our  patient  showed  anger  and  said:  "You 
fool,  I'm  all  right;  I've  gotten  rid  of  it"  (the  attack). 


107 

The  next  day  our  patient  said:  "I  can't  understand  why 
that  old  feeling  (epigastric  aura)  came  up  in  my  stomach 
for  the  past  two  or  three  days;  it  must  have  been  on  account 
of  the  weather,  or  something  not  going  right  outside  my 
recollection  now." 

It  may  be  added  that  no  actual  attacks  appeared  at  this 
time,  and  none  occurred  for  over  two  weeks  after  the  above 
notes  were  made,  during  which  period  the  patient  felt  neither 
depressed  nor  sad. 

Chart  No.  III. 


1    2 

.  3  * 

5 

6 

7 

8 

9 

10 

li 

12 

13 

14 

IS 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

2930  31 

6RAHDMAL 

HI 

1       1 

| 

M 

1 

PETIT  MAL 

1 

Patch  ic 

Phenomena 

J 

Elation 

i 

1 

AN6ER 

H 

IN 

1 

J 

Irritation 

y 

II 

II 

1 

I 

LETHAR6Y 

i 

!'! 

1 

Directed 

J 

1  | 

spontaneous 
Interest 

i 

1 

;■:■ 

® 

H 

\l 

1 

H 

1 

1 

1 

M 

9 

1 

Z 

2 

1 

1 

1 

1 

i 

u 

B 

1  ll  ■ 

Chart  III.  On  the  initiation  of  the  observation  period 
it  was  noted  that  the  patient  had  been  irritable  and  in  an  un- 
stable mood.  She  laughed  at  little  or  nothing,  became 
exhilarated  and  talked  loudly  when  in  the  company  of 
others.  She  found  fault  with  trivial  things.  On  going  to 
bed  she  had  a  grand  mal  attack.  She  passed  the  following 
day  without  attacks,  but  in  the  evening  had  another  major 
seizure  following  a  period  which  began  with  irritation,  anger, 
and  finally  elation.  Next  day  she  was  irritable  and  angry 
and  refused  to  cooperate.  The  following  day,  however, 
there  was  an  effort  on  her  part  to  comply  with  the  prescribed 
routine  but  later  in  the  day  her  interest  lagged  and  she  be- 
came irritable,  angry,  then  elated,  and  later  had  another 
grand  attack. 

On  the  5th  she  was  irritated  at  everything  and  became 
very  angry  when  directed  to  certain  duties.  But  on  the  6th 
she  again  made  an  effort  at  readjustment  and  her  interest 
for  a  time  was  spontaneous,  but  she  soon  tired,  and  lapsed 
into  a  state  of  lethargy  which  was  soon  followed  by  the  old 
irritable  state.     The  following  day  another  period  of  spon- 


108 

taneous  interest  was  noted  for  a  time,  but  the  irritability 
soon  reappeared  and  she  had  a  grand  mal  attack. 

The  next  three  days  the  patient  appeared  happy  and  con- 
tented, going  about  her  daily  tasks  without  being  irritated 
or  annoyed,  but  on  the  11th  she  resented  being  told  by  her 
nurse  she  must  act  in  a  certain  way  when  in  the  company 
of  the  other  guests,  that  she  must  not  be  so  talkative,  etc. 
She  became  angry  and  irritable  and  remained  in  this  mood 
for  the  rest  of  the  day. 

Following  the  reactions  noted,  there  ensued  a  period  of 
freedom  from  attacks  for  over  eighteen  days.  During  this 
time  the  patient  was  active  and  cheerful,  going  about  the 
daily  routine  in  a  happy  state  of  mind.  She  devoted  her- 
self to  her  music  and  tennis  and  cooperated  with  her  nurse 
in  every  way.  About  this  time  her  mother  took  exception 
to  certain  articles  of  jewelry  and  finery  that  the  patient 
wished  to  wear.  Her  mother  took  her  to  task  rather  severely 
and  the  patient  retired  to  her  room  and  cried  for  over  an 
hour.  She  finally  went  to  her  mother  and  said  she  thought 
she  saw  the  matter  in  the  right  light  and  would  comply  with 
her  request.  This  episode  with  the  mother  took  place  at  10 
in  the  morning,  and  at  12.30  she  had  a  typical  grand  mal 
attack. 

Chart  No.  IV. 


1 

2 

3 

4 

5 

6 

7 

&  i 

>  10 

II  1 

2  13 

14 

15 

IGI 

7  18 

19 

20 

21 

22 

23 

24 

252 

627  2 

829 

3031 

Grand  mal 

J 

1 

1 

Petit  Mai 

1 

1  11 

II 

1 

| 

| 

PSYCHIC 
PHENOMENA 

u 

1 

L 

ELATION 

1 

1 

u 

1 

1 

. 

ANGER 

i  ii  ii  ii  ii  minimi  ii  muni  ■ 

1 

I.I 

1.1 

J 

| 

Irritation 

n 

i 

1 

1 

1 

I 

a  1 

1  I 

i  ,: 

\i 

H 

9 

1 

II 

H 

1 

LETHARGY 

H 

1 

1 

$ 

1 

t 

j  i .; 

1   ''    ! 

3  I 

toi 

1 

I  I 

1 

■ 

i 

R 

i 

1  1 

■  1 

8 

Directed 
Interest 

i  ii  ii  ii  ii  minimi  ii  n  ii  ii  ii  ii  ii  ii  ii  ii  ii  ii  ii  ii  ii  ii  mil  11  imni 

SPOIITANEOUS  I 


i  i  \m 


Chart  IV.  A  fellow  patient  died  at  the  Club,  and  this 
seemed  to  increase  the  irritable  state  already  present  when 
our  patient  arrived.  She  had  dreams  of  fright.  She  be- 
came depressed  and  moody,  sat  about  in  a  listless  fashion, 
and  became  angry  when  told  to  follow  out  the  simplest  direc- 
tions.    This  condition  lasted  from  the  1st  to  the  5th.     Then 


109 

for  three  days  she  tried  to  do  as  the  nurse  suggested  and  on 
each  occasion  became  elated,  laughed  and  talked  with  her 
nurse,  saying  that  she,  the  patient,  was  a  good  girl  and 
would  do  everything  she  was  told;  but  the  effort  was  too 
great,  and  out  of  the  elated  state  there  developed  first  petit 
mal  and  then  grand  attacks.  She  again  became  irritable, 
depressed,  and  made  no  effort  to  adjust  herself,  and  the 
three  days  following  she  had  attacks  of  a  more  or  less  severe 
type.  The  slightest  difficulties  seemed  mountains  to  her. 
She  complained  constantly  of  everything  and  everybody. 
She  would  put  her  hands  over  her  eyes,  jerk  her  shoulders, 
clasp  and  unclasp  her  hands,  and  otherwise  show  the 
nervous  tension  under  which  she  was  laboring. 

Then  followed  three  days  in  which  she  was  obedient, 
seemed  anxious  to  please,  and  was  solicitous  of  the  nurse's 
comfort;  but  she  soon  tired  of  this  attitude  and  became  irri- 
table. The  next  day  she  went  through  the  same  phase  of 
trying  to  keep  up  with  the  routine,  became  irritable  and  then 
elated,  and  said:  "  Oh,  my  Lord,  will  I  ever  be  like  other 
people!  "  A  slight  attack  followed,  after  which  she  became 
excited  and  angry.  She  became  angry  over  a  bill  she  had 
paid  the  newspaper  man,  and  declared  he  was  a  cheat.  She 
kept  talking  about  it  during  the  day  and  carried  it  about  in 
her  hand.  Looking  abstractedly  into  space  she  said  to  the 
nurse:  "That  bill — I  am  going  to  have  an  attack."  She 
lost  consciousness  for  a  few  seconds  and  then  began  to 
undress,  next  she  twisted  her  body,  putting  her  hands  under 
her  back  and  lifting  her  entire  body,  kicking  her  feet,  and 
laughing  and  trying  to  talk.  She  was  induced  to  lie  down, 
when  she  assumed  the  fcetal  position  and  went  to  sleep. 
From  then  on  until  the  end  of  the  month  she  made  efforts  to 
keep  up  with  the  daily  routine,  but  found  fault  with  every- 
thing, becoming  excited,  irritated,  depressed  and  elated  by 
turns,  and  had  several  attacks. 


110 
Chart  No.  V. 


m  DAY 

2*P  DAY 

s 

7 

7 

8 

fc» 

(O   II 

GRAND  MAL 

II 

Petit  mal 

PSYCHIC 
PHENOMENA 

Elation 

Anger 

■ 

Irritation 

I II 1 
nun 

Lethargy 

i  ii  ii  ii  ii  m 

DIRECTED 
INTEREST         {J 

1 

1 

SPONTANEOUS      §§ 
INTEREST         11 

, 

, 

— 

, 

' 

, 

1 

, 

, 

Chart  V.  The  patient,  aged  12,  had  been  free  from 
grand  mal  attacks  for  several  weeks  when  the  following 
incident  occurred: 

Boy-like,  he  had  helped  himself  to  some  fruit  which  he 
was  not  permitted  to  indulge  in.  He  was  detected  and  cen- 
sured. He  immediately  ceased  his  spontaneous  interests 
and  did  poorly  at  directed  ones.  He  was  told  he  must  apol- 
ogize and  restore  the  stolen  fruit  and  that  his  comrades  would 
be  told  of  his  misconduct.  He  made  no  effort  toward  hand- 
ling the  situation,  was  greatly  dejected  and  experienced  a 
keen  mental  anguish.  He  had  an  intense  conflict  with  him- 
self as  to  how  he  might  get  out  of  the  situation  rather  than 
take  the  simple  course  of  acknowledging  his  fault  and  mak- 
ing apologies,  thus  regaining  the  usual  friendly  relations  of 
the  people  about  him.  He  wished  especially  not  to  be  shamed 
in  the  eyes  of  his  boy  companions.  In  this  state  of  mind 
he  went  to  bed.  He  moaned  and  tossed  in  his  sleep,  and  on 
waking  next  morning  he  was  listless  and  indifferent,  refus- 
ing to  follow  the  ordinary  routine.  All  the  forenoon  he 
continued  to  be  lethargic  and  indifferent,  gaping  and  yawn- 
ing, and  at  11  o'clock  had  a  grand  mal  attack.  Immediately 
after  the  attack,  although  he  had  made  no  effort  at  adjust- 
ing the  difficulties,  he  appeared  greatly  relieved  and  went 


Ill 

about  his  routine  duties  as  if  the  whole  matter  had  been 
quite  removed.  However,  he  was  not  amnesic  for  events 
that  had  occurred. 

The  foregoing  system  of  charting  epileptic  reactions  shows 
that  it  is  not  only  feasible  but  desirable  that  each  and  every 
case-history  should  have  a  similar  graphic  chart  for  easy 
reference  in  the  case  summary.  Inasmuch  as  the  funda- 
mentals of  the  tantrum  reactions  of  the  "difficult"  child 
are  embraced  in  this  scheme  of  chart  recording,  it  is  obvi- 
ous that  this  method  might  be  extended  for  use  in  other 
types  of  reactions  simpler  than  those  leading  up  to  epileptic 
seizures. 

Section  V. 

EXPERIMENTAL   STUDY   OF   THE   MENTAL  RESTORATION  OF 
A   DETERIORATED    EPILEPTIC. 

As  has  been  suggested  a  number  of  times  in  this  study, 
the  deterioration  of  the  epileptic  may,  in  some  measure  at 
least,  be  dependent  on  mental  factors — on  the  maintenance 
of  his  interest  and  habit  reactions.  In  so  far  as  this  is 
true,  the  clinical  picture  of  this  deterioration  ought  to  be 
modifiable  and  the  best  material  with  which  to  demonstrate 
this  would  be  a  case  where  the  epilepsy  comes  on  late  in 
life  where  a  fair  foundation  of  mental  habit  has  once  ex- 
isted on  which  to  build.*  An  excellent  opportunity  for 
such  a  therapeutic  attempt  presented  itself  some  three  years 
ago  in  the  case  of  a  man  who  had  not  developed  his  con- 
vulsions until  his  38th  year  but  in  three  years  had  shown 

*  The  plan  of  treatment  was  aided  in  no  small  part  by  the  experience  obtained 
in  the  recovery  of  V.  A.  S.,  a  chronic  deteriorated  epileptic,  mentioned  first  as 
Case  II  in  my  article  "Curability  of  Idiopathic  Epilepsy,"  published  in  the 
Archives  of  Internal  Medicine,  January,  1912,  Vol.  9,  and  detailed  in  "  The  Nature 
and  Pathogenesis  of  Epilepsy,"  N.  Y.  Medical  Journal,  February  27  to  March 
27,  1915.  In  this  case  of  extreme  memory  and  habit  disorganization  a  simple 
and  sensible  scheme  of  re-establishing  a  series  of  spontaneous  interests  was 
successfully  made  use  of.  This  case  was  also  commented  on  by  Dr.  John  T. 
MacCurdy  in  his  article  "A  Clinical  Study  of  Epileptic  Deterioration,"  Psychi- 
atric Bulletin,  Vol.  I,  April,  1916,  p.  257.  In  this  article  MacCurdy.  in 
addition  to  giving  an  excellent  descriptive  study  of  epileptic  dementia,  also  dis- 
cusses the  possibility  of  mental  factors  having  a  share  in  the  development  of 
the  deterioration  of  some  epileptics,  and  for  the  first  time,  he  formulates  the 
mechanisms  by  which  these  mental  factors  may  be  conceived  to  operate.  A 
study  of  MacCurdy's  paper  is  therefore  advisable  in  connection  with  this 
account  of  more  empiric  treatment. 


112 

grave  dementing  symptoms.  In  the  absence  at  that  time  of 
any  work  on  this  aspect  of  the  disease  the  treatment  adopted 
was  purely  empiric  but  the  results  are  no  less  instructive  on 
that  account.  Unfortunately  he  died  of  a  grippe  pneumonia 
(March  5,  1914)  after  eighteen  months  of  treatment,  so  that 
we  can  not  say  what  the  ultimate  results  might  have  been. 
The  aim  of  this  report  is,  therefore,  not  to  claim  a  specific 
therapy  for  this  condition  but  merely  to  demonstrate  how 
accurately  his  improvement  ran  parallel  to  certain  psycho- 
therapeutic experimental  measures. 

His  family  history  showed  a  definite  heredity  of  feeble- 
mindedness and  insanity  but  no  definite  epilepsy. 

The  makeup  was  distinctly  of  the  epileptic  type.  In 
school  he  was  slow  in  acquisition,  particularly  with  those 
subjects  which  required  concentration.  It  is  important  to 
note  that  his  favorite  study  was  drawing.  He  was  abnor- 
mally sensitive  in  the  school  period  of  life,  "  feeling  hurt  for 
days"  when  criticized,  and  reconciling  himself  to  discipline 
only  with  great  effort.  Later  in  life,  when  confronted  with 
mistakes,  he  tried  to  make  good  his  excuses  and  if  this 
failed  would  become  abusive,  excited  and  filially  absent 
himself  for  hours  from  the  troublesome  environment.  He 
had  few  friends  because  he  was  hypercritical  of  his  acquaint- 
ances and  insincere  in  his  protestations  of  affection.  What 
superficial  intimacies  he  enjoyed  never  lasted  long,  as  he 
was  too  self-opinionated  to  maintain  these  friendships.  In 
his  earlier  years  his  chief  interest  seemed  to  lie  in  fussing 
about  his  home,  while  later  in  life  the  interest  centered 
almost  entirely  on  his  father's  business,  which  it  was  ex- 
pected he  would  inherit.  He  never  paid  any  attention  to 
games  or  sports  of  any  kind.  In  general  one  might  say 
that  he  was  preponderantly  self-centred  with  little  ability 
to  objectivate  his  interest  or  get  in  rapport  with  others. 

It  is  hard  to  say  when  his  epilepsy  began,  for,  years  before 
convulsions  occurred,  there  were  mental  changes  highly 
typical  of  that  disease.  This  deterioration  had  a  gradual 
onset,  the  abnormalities  of  his  character  passing  imper- 
ceptibly over  into  definite  symptoms.  On  leaving  school 
there  became  evident  an  increasing  difficulty  in  cooperating 


113 

with  others  and  he  grew  steadily  less  able  to  adapt  himself 
to  new  situations.  His  sensitiveness  increased  to  a  morbid 
degree,  for  on  slight  provocation  he  would  turn  irritable, 
abusive  and  finally  lapse  into  sullen  silence,  not  speaking 
to  the  offender  for  days.  Naturally,  with  this,  he  became 
less  respectful  of  the  rights  of  others  and  much  less  tactful. 
Coincidently,  his  interest  in  matters  not  directly  affecting 
himself  grew  steadily  narrower.  His  business — his  whole 
life — contracted  into  routine  ;  he  was  finicky  in  demanding 
order  and  precision.  Frequently  he  lapsed  into  day  dreams 
of  living  back  at  home  with  his  mother,  although  he  was 
married  and  had  children  of  his  own.  Interest  withdrawn 
from  the  world  around  him  centered  on  his  own  body ;  he 
became  hypochondriacal.  Worry  over  his  health  often  led 
to  restlessness  and  then  long  periods  of  sullen,  moody 
silence. 

Life  was  becoming  too  great  a  strain  on  him  and  at  38 
his  first  convulsion  occurred.  The  circumstances  are  sig- 
nificant. He  spent  a  large  part  of  one  day  at  a  business 
conference  where  he  had  great  difficulty  in  controlling  his 
annoyance  at  what  he  called  the  "  pig-headedness "  of 
his  associates.  Before  the  meeting  was  over  he  became 
pale,  restless,  trembled  and  had  a  headache.  During  the 
day  he  had  taken  little  food,  went  home  successful,  but  still 
worrying  about  the  outcome  of  his  schemes,  ate  a  hearty 
dinner  and  then  had  a  grand  mal  attack.  His  subsequent 
seizures  usually  showed  similar  prodromata.  They  repeated 
themselves  with  ever  increasing  frequency,  reaching  a  rate 
of  two  a  week. 

The  mental  changes,  which  up  to  this  time  had  been 
slowly  progressing,  now  advanced  at  greater  speed.  He 
totally  lost  his  ability  to  adapt  himself  to  anything  outside 
his  business;  interest  in  general  activities  went  with  the 
loss  of  adaptation  and  soon  the  business  itself  ceased  to 
attract  him,  although  this  was  the  last  interest  to  disappear. 
Intellectual  degradation  set  in,  for  pari  passu  with  loss  of 
interest  his  memory  faded  out.  He  was  reduced  to  staying 
at  home,  paying  no  attention  to  anything  except  to  his  appe- 
tites, disregarding  even  his  family.  With  this  inactivity  he 
naturally  began  to  suffer  physically. 


114 

He  came  to  me  for  treatment  after  the  convulsions  had 
been  present  for  three  years.  It  was  found  that  he  had  a 
poor  circulation,  flabby  musculature,  enterocolitis  and 
serious  constipation.  Mentally  he  lacked  any  spontaneity, 
was  dull  in  appearance  and  had  such  a  memory  defect  that 
he  could  retain  a  simple  fact  no  longer  than  a  minute  or  so. 

The  treatment,  as  has  been  said,  was  purely  experimental. 
The  first  efforts  were  naturally  directed  towards  improving 
his  physical  condition.  This  period  lasted  for  six  months 
and,  during'  this  time,  although  he  became  bodily  well, 
there  was  no  result,  so  far  as  either  his  convulsive  or  deteri- 
oration symptoms  were  concerned. 

In  the  next  period  of  eighteen  months  (terminated  by  his 
death)  the  treatment  was  focussed  on  the  mental  aspects  of 
his  condition  This,  for  some  time,  seemed  a  hopeless 
task.  The  usual  routine  occupations  failed  to  awaken  a 
spark  of  enthusiasm  in  him.  He  was  put  at  cutting  wood, 
wood-carving,  shop  work  and  handicrafts  of  various  kinds 
but  all  to  no  avail.  He  neither  showed  any  interest  in  them 
nor  did  his  convulsions  diminish  in  frequency.  A  whole 
series  of  occupational  studies  were  tried — travel  and  nature 
studies,  horticulture;  these,  too,  failed  of  result.  It  now 
became  evident  that  nothing  could  be  grafted  on  him,  so 
the  more  rational  scheme  was  attempted  of  reawakening 
his  strongest  interests,  of  appealing  to  what  had  previously 
meant  most  to  him — his  feeling  of  self-importance  and  his 
business.  This  was  successful  and,  as  his  intellectual  pro- 
cesses began  to  accelerate,  the  simpler  stimuli  were  made 
more  complex. 

Inasmuch  as  he  had  shown  considerable  capacity  for 
drawing,  it  was  thought  this  would  be  the  best  method  of 
inducing  a  mental  reintegration.  He  was  asked  to  make 
maps  of  his  own  town  from  memory  (he  was  now  living  in 
another  part  of  the  country  under  treatment).  Day  by  day 
he  was  led  to  make  them  more  and  more  detailed,  drawing 
in  houses,  roads,  etc.  The  first  map  he  drew  showed  only 
crude  outlines  with  practically  no  details.  After  he  had 
made  a  map  of  his  home  town,  he  outlined  similar  detailed 
drawings  for  two  other  places.     It  was  customary  for  him 


115 

to  move  back  and  forth  every  six  months  from  the  country 
to  the  city.  His  capacity  to  remember  the  city,  which  he 
enjoyed  much  more  than  the  country,  was  shown  in  the 
ability  with  which  he  mapped  the  former.  In  the  city  he 
had  more  social  life,  and  it  was  more  like  the  type  of  his 
home  town. 

So  soon  as  his  interest  became  thoroughly  aroused  in  map 
drawing,  he  became  sociable  with  the  other  guests,  and 
explained  the  community  life  that  went  on  in  the  various 
places  detailed  on  his  maps.  Whereas  before  he  had  always 
been  very  retiring,  he  now  began  to  engage  in  conversations 
with  others  in  the  group.  His  main  topic  was  his  maps 
and  the  things  they  suggested  relative  to  business  and 
society.  This  created  his  first  spontaneous  topic  of  con- 
versation. 

As  a  young  man  he  had  shown  a  great  interest  in  atmos- 
pheric conditions,  the  tides,  etc.;  he  was  now  induced  to 
get  a  barometer,  whose  readings  he  took  great  pains  to 
record  morning  and  evening.  The  significance  of  the 
barometric  changes  had  been  one  of  the  chief  topics  of  con- 
versation at  home  as  they  had  a  direct  bearing  on  the  family 
business.  All  these  little  attentions  revived  his  interest  in 
his  home  surroundings  and  his  earlier  contacts  with  life 
which  he  had  so  negligently  allowed  to  fall  away.  At  this 
point  he  began  to  show  some  insight  as  to  the  manner  in 
which  his  mental  disintegration  had  come  about,  and  spon- 
taneously began  to  undertake  more  self-direction  in  carry- 
ing out  this  training  treatment.  He  turned  his  attention  to 
reviving  his  memory  and  took  more  heed  of  the  latter  than 
of  the  occurrence  of  attacks  which  had  before  filled  his 
whole  horizon. 

His  interest  still  ran  in  rather  slender  channels,  for  wood- 
carving  easily  fatigued  him  because  his  interest  in  it  was 
not  keen  except  in  so  far  as  he  saw  a  possibility  of  utilizing 
it  in  his  business.  While  carving,  he  day-dreamed  and 
watched  the  clock,  waiting  for  the  end  of  the  lessons;  and 
had  more  frequent  attacks  at  this  occupation  than  at  any 
other.  However,  when  he  carved  a  chest  for  his  family, 
placing   their   coat-of-arms  on    it,  'he  worked  very   hard. 


116 

Carving  then  had  an  attraction  for  him,  which  it  never 
exerted  before.  All  handicrafts  still  remained  quite  second- 
ary to  his  interest  in  map-drawing,  especially  in  what  con- 
cerned the  exact  location  of  his  manufacturing  plant  and 
all  the  details  of  the  family  home  and  those  of  the  employees 
in  the  village.  Continuing  the  map  work,  he  drew  it  to 
scale  and  outlined  all  the  ground  plans  of  the  manufactur- 
ing plant.  The  latter  was  very  difficult  and  had  to  be 
undertaken  for  very  short  periods  of  time.  It  seemed  to 
fatigue  him  greatly  to  recollect  the  exact  proportional  rela- 
tionships of  the  various  machines  in  the  shops.  He  liked 
the  work  nevertheless,  and  so  soon  as  he  began  to  do  it 
fairly  well,  he  became  much  elated  over  the  accomplish- 
ment. 

The  improved  mental  attitude  and  interest  in  regaining 
his  memory  were  soon  reflected  in  the  lessened  severity  of 
attacks  and  their  much  less  disturbing  influence  upon  his 
daily  activities  and  interests.  After  several  months  of  this 
educational  training  his  sociability  was  noted  towards  others 
outside  the  immediate  household  where  he  lived.  Although 
he  was  still  unable  to  talk  on  varied  subjects,  he  showed  a 
willingness  to  take  an  interest  in  topics  that  were  related  to 
those  he  had  talked  about  at  home.  An  ambition  for  a 
friendly  contact  with  a  larger  group  developed  him,  and  to 
re-establish  the  social  ties  previously  allowed  to  lapse, 
became  a  sort  of  mania  with  him.  The  desire,  however, 
entailed  new  work;  in  order  to  do  this  well  he  had  to  remem- 
ber many  things  that  were  not  even  remotely  related  to  the 
subjects  which  had  been  discussed  in  his  home.  In  other 
words,  he  had  to  remember  incidents  about  which  he  had 
no  particular  personal  concern.  He  had  to  cultivate  a 
liking  for  subjects  because  the  new  acquaintances  liked 
them.  This  task  was  very  difficult,  but  still  he  persisted  as 
it  was  essential  to  the  fulfilment  of  his  aim.  In  order  to 
encourage  this  tendency  of  rebuilding  his  social  contacts, 
he  was  given  a  little  book  in  which  to  jot  down  the  names, 
characters,  and  subjects  of  interest  which  his  companions 
possessed.  He  spent  much  time  in  going  over  them,  and 
sought  continued  tutoring  in  recalling  these  data.     Even 


117 

after  several  months  of  this  training  he  had  to  be  prompted, 
like  a  reciting  schoolboy,  with  a  name  or  a  sentence  from 
the  book  before  he  could  undertake  these  new  conversations. 
The  amount  of  memory  defect  to  be  overcome  may  be  justly 
estimated  when  it  is  stated  that  at  the  beginning  he  could 
not  remember  a  single  name  of  his  household  associates 
with  the  exception  of  his  own  nurse. 

In  the  last  six  months  of  the  training,  he  began  to  take 
more  interest  in  plays  and  various  forms  of  entertainment. 
At  first  he  paid  attention  only  to  the  personnel  in  the  play 
productions.  So  soon  as  he  was  able  to  recall  the  substance 
and  thread  of  the  plot,  he  showed  a  genuine  enthusiasm  in 
the  performance  itself.  He  never  cared  for  moving  pictures 
as  the  rapidity  of  action  was  too  fatiguing;  the  sense  of  the 
play  was  received  only  through  the  one  avenue  of  sight 
and  he  could  not  grasp  the  meaning.  To  increase  his  fund 
of  ideas  his  companions  often  asked  him  to  give  them  a 
resume  of  the  different  acts  he  had  seen  and  what  he  con- 
sidered most  interesting  about  them.  This  scheme  enabled 
him  to  have  something  definite  to  contribute  to  his  friends, 
and  it  increased  his  own  confidence  and  self-importance. 
Of  course  the  things  he  remembered  at  first  always  had  a 
more  or  less  personal  interest.  It  was  interesting  to  note 
what  a  lopsided  view  of  plays  he  took.  His  description 
often  tallied  poorly  with  that  of  other  individuals  who  had 
witnessed  the  same  productions. 

Not  the  least  interesting  aspect  of  his  methods,  in  reawak- 
ing  his  long  disused  memory,  was  the  cleverness  with  which 
he  would  either  find  out  the  main  facts  which  he  had  lost, 
or  avoid  those  issues  in  conversation.  If  he  lacked  the 
connecting  link  of  a  particular  name,  or  the  time  a  certain 
thing  occurred,  he  would  adroitly  get  these  facts  from  his 
companions  and  then  launch  the  entire  conversation  to  suit 
himself.  The  requisitioned  data  were  always  furthest 
away  from  the  concrete  and  usually  quite  removed  from 
his  personal  interest. 

His  daily  reading  gradually  extended  from  an  almost 
complete  engrossment  in  his  little  home  paper  to  world-wide 
affairs  gleaned  from  the  city  dailies,  and  his  interest  in  the 


118 

activities  of  the  people  employed  in  his  manufacturing 
plant  gradually  widened. 

The  influence  which  this  improved  mental  state  had  upon 
his  everyday  life  was  interesting.  For  instance,  the  habit 
of  gorging  himself  with  food  gradually  lessened — not  that 
he  cared  less  for  it,  but  because  he  noticed  others  did  not 
do  so.  He  desired  to  conform  to  the  regulations  which 
others  adopted.  He  did  very  well  on  a  lighter  diet;  he  was 
able  to  eliminate  many  of  the  heavy  meats,  and  lost  entirely 
his  former  habit  of  over-indulging  in  sweets.  His  habits 
of  dress  also  changed.  So  soon  as  he  became  more  observ- 
ant of  people  about  him,  he  gave  up  wearing  clothes  cut 
only  in  certain  styles.  His  manner  of  dress  was  less  rigid 
and  more  easily  adapted  to  season,  time,  and  place  like  that 
of  others  about  him. 

As  his  memory  continued  to  improve  and  the  scope  of  his 
interest  increased,  he  realized  the  necessity  of  getting  rid  of 
his  disorder  so  that  he  might  again  resume  his  position  in 
the  firm.  As  he  gained  a  better  insight  into  his  innate 
defects  of  memory,  he  saw  how  necessary  it  would  be  to  rid 
himself  of  them  as  well  as  of  the  attacks.  Formerly  he  had 
thought  that  all  he  had  to  do  was  to  return  home  and  take 
entire  charge,  when  he  would  be  able  to  handle  everything 
without  counsel  or  advice.  Latterly  he  remarked,  ' '  1  see 
now  that  I  can't  keep  up  with  the  business,  but  I  feel  I 
could  be  of  help  to  my  brothers.  Of  course  I  would  not 
attempt  to  carry  on  a  third  partnership.  I  would  do  the 
things  laid  out  for  me,  that  I  could  do  and  yet  keep  my 
health." 

One  of  the  character  alterations,  last  and  least  changed 
by  the  treatment,  was  the  feeling  of  sympathy  with  and 
confidence  in  those  concerned  with  improving  his  physical 
and  mental  welfare,  a  characteristic  so  constantly  absent  in 
epileptics.  It  always  seemed  difficult  for  him  to  desire  a 
completely  sincere  and  sympathetic  relationship.  The 
central  core  of  his  egoistic  attitude  seemed  to  preclude  the 
possibility  of  attaining  this  high  attribute;  in  consequence 
his  social  rapport,  even  when  the  treatment  had  been  long 
maintained,  was  often  not  very  strong.     It  could  be  easily 


119 

broken  by  the  slightest  feelings  of  suspicion  or  distrust.  A 
seeming  carelessness  or  indifference  on  the  part  of  the 
individuals  concerned  in  helping  him  with  his  problems 
was  almost  immediately  widened  into  a  chasm,  and  if  allowed 
to  endure  for  long  seemed  to  constitute  an  impassable 
barrier  to  further  progress.  It  showed  that  the  fundamental 
fault  in  his  instinctive  makeup  had  been  by  no  means  slight. 

How  far  his  progress  might  have  gone  had  he  not  died  one 
can  not  say.  It  must  be  admitted  that  here,  as  in  similar 
cases,  the  defects  in  the  primary  instincts  retarded  prog- 
ress. One  often  fails  in  restoring  memory  and  reforming 
habits,  or  at  least  in  bringing  them  up  to  the  standard  of 
normal  reactions.  The  very  nature  of  the  character  defect 
from  which  the  epileptic  suffers  precludes  this  consumma- 
tion. Undoubtedly  the  retention  of  mental  stability  in  the 
epileptic  individual  (as  in  ourselves)  must  ever  be  condi- 
tioned upon  a  willingness  and  desire  to  lose  nothing  of 
original  endowment  and  its  after-development  in  adoles- 
cence. 

To  summarize  the  case:  We  have  here  a  man  whose 
primary  endowment  of  the  epileptic  character  precluded  a 
normal  and  stable  adolescence.  In  adult  life  when  the 
stress  of  social  and  business  adaptations  became  too  great, 
his  imperfect  character  development  began  to  deteriorate. 
This  deterioration  went  on  for  years.  For  a  time  it  was 
definitely  noticeable  only  to  those  most  immediately  associ- 
ated with  him.  First  he  had  mental  reactions  of  the  epilep- 
tic type  in  various  social  and  business  settings.  As  he 
grew  older  and  the  stress  of  work  and  home  affairs  increased, 
his  defects  expressed  themselves  in  grand  mal  attacks  of  a 
classic  type.  Coincident  with  this  mishap  the  physical 
habits  on  which  the  maintenance  of  good  health  depends, 
also  underwent  dilapidation.  A  severe  form  of  chronic 
epilepsy  soon  followed  and  the  patient  presented  evidences 
of  a  progressive  mental  deterioration.  Under  a  hygienic 
living  he  slowly  mended  his  physical  health.  His  epilepsy 
and  mental  deterioration,  however,  remained  unchanged 
until  the  mental  training  treatment  above  outlined  was  put 
in  operation.     In  a  period  of  eighteen  months  he  regained 


120 

much  of  his  memory  and  initiative.  His  mental  horizon 
was  broadened  and  his  social  interests  were  in  process  of 
restoration.  His  epileptic  attacks  were  diminished  to  one- 
half  of  their  former  frequency  and  severity.  The  improve- 
ment, which  was  slow  in  the  beginning,  gradually  extended 
from  a  pure  memory  rehabilitation  to  that  of  a  comprehen- 
sive character  restoration,  and  gave  promise  of  even  greater 
results  had  the  experiment  not  been  interrupted  by  death. 
The  case  has  been  detailed  at  some  length  to  illustrate  what 
may  possibly  be  done  for  similar  epileptic  individuals  even 
when  deterioration  is  far  advanced.  Although  many 
chronic  epileptics  may  not  entirely  recover,  one  should  not 
despair  of  improving  their  lives  to  the  advantage  of  all 
concerned. 

The  objection  might  be  made  that  the  improvement  in 
this  case  was  not  the  result  of  the  mental  treatment  but 
rather  of  a  betterment  in  some  obscure  physical  condition, 
the  relative  recovery  with  the  treatment  being  a  mere 
coincidence.  No  final  denial  of  this  claim  can  be  made, 
nor  is  this  case  cited  as  an  argument  in  faver  of  the  exclu- 
sively psychic  origin  of  epileptic  deterioration.  The  object 
of  the  publication  is  to  give  an  example  of  symptomatic 
improvement  proceeding  hand  in  hand  with  reawakened 
interest.  If  deductions  may  be  drawn  from  this  case  they 
would  be  that  no  superficial  nor  perfunctory  stimulation 
will  benefit  an  epileptic.  An  inherent  fundamental  interest 
must  be  touched.  Results  obtained  from  this  first  effort 
may  slowly  be  added  to,  by  the  cautious  increase  of  demands 
on  the  patient's  energy.  Progressive  improvement,  how- 
ever, comes  only  when  patient  himself  begins  to  realize 
and  conquer  his  difficulties. 

Section  VI. 

A   STUDY   OF  THE  MENTAL   MECHANISM   BY   WHICH 

ARRESTS   HAVE   BEEN   BROUGHT  ABOUT   IN 

SEVERAL  CASES  OP  EPILEPSY. 

Before  an  intensive  study  of  the  epileptic  makeup  was 
made,  the  character  and  temperament  of  such  individuals 
were  thought  to  be  caused  by  the  after-developing  disease, 


121 

but,  as  has  been  shown  by  many  careful  studies,  the  in- 
stincts and  trends  of  such  an  epileptic  constitution  antedate 
for  years  the  onset  of  the  epileptic  reactions,  and,  indeed, 
are  a  part  of  the  original  endowment.  It  has  also  been  held 
that  the  mental  deterioration  is  a  direct  result  of  the  seiz- 
ures in  spite  of  the  fact  that  many  cases  do  not  deteriorate 
in  a  life-long  epileptic  career,  while  many  other  epileptics 
having  few  seizures  deteriorate  quickly.  We  seem  to  have 
laid  too  much  stress  upon  the  seizure  phenomena  in  epilepsy 
as  causal  factors  to  the  mental  states  attending  the  disease. 

When  it  is  shown  that  a  particular  epileptic  has  begun  to 
readjust  his  bad  adaptation  to  life,  one  is  apt  to  believe  the 
cessation  of  the  attacks  has  accounted  for  the  improved  men- 
tal condition,  but  such  a  direct  causal  relationship  can  not 
be  maintained,  as  the  mental  state  often  enough  shows  signs 
of  mending  before  the  frequency  of  attacks  is  diminished. 

The  apparent  truth  of  the  matter  would  seem  to  be  that  a 
better  mental  and  physical  adjustment  enables  the  patient 
to  meet  the  fundamental  biologic  demands  of  his  existence 
more  capably.  The  mind,  therefore,  improves,  and  the 
attacks  decrease  also. 

In  giving  the  following  case  notes,  one  should  not  infer 
that  the  ordinary  regulations  of  diet  and  general  physical 
health  rules  were  not  also  used  in  treating  and  caring  for 
these  cases.  But  the  outstanding  fact  is,  that  with  the  in- 
stitution of  the  latter  alone,  the  symptoms  did  not  especially 
improve  until  the  mental  treatment  had  been  given.  The 
importance  of  the  latter  is  the  point  I  wish  to  make  in  this 
section,  a  study  of  the  end  results  in  some  arrested  cases. 

The  first  case  is  that  of  a  man  now  33  years  old,  whose 
epilepsy  first  became  pronounced  at  17  years,  although  he 
had  petit  mal  at  7  or  8  years.  With  the  exception  of  one 
attack  three  years  ago,  details  for  the  recurrence  of  which 
will  be  given,  this  man  has  had  an  arrest  of  his  epilepsy  for 
the  past  ten  years.  He  is  the  oldest  of  four  brothers.  There 
is  no  neuropathic  heredity.  The  patient  was  a  highly 
sensitive,  crying  baby;  under  a  rather  rigid  parental  disci- 
pline, he  grew  to  repress  his  violent  tempers  and  became 
quite  "  rigid  "  in  his  daily  deportment.     At  7  to  8  he  got  on 


122 

poorly  at  school.  While  he  learned  easily  he  had  an  intense 
dislike  for  his  teacher.  He  grew  pale  and  listless  and  soon 
began  to  have  headaches,  becoming  very  irritable.  His 
sensitiveness  grew  apace;  when  punished  he  sullenly  smoth- 
ered his  resentment,  and  "set  his  teeth."  He  steadily 
became  more  rigid  in  his  cooperation  with  other  children 
and  soon  had  to  be  taken  out  of  school  at  intervals.  About 
this  time  it  was  noted  that  he  day-dreamed.  Finally,  these 
periods  of  abstraction  were  seemingly  replaced  by  petit  mal 
attacks.  The  introduction  of  an  entirely  care-free  life  soon 
brought  these  absences  under  control.  He  then  got  along 
quite  all  right  until  he  reached  his  17th  year,  at  which  time 
he  was  ready  to  graduate  from  high  school.  Close  applica- 
tion and  the  stress  of  keeping  up  with  his  class  at  this  time 
engendered  pallor,  increased  irritability  and  sensitiveness, 
and  he  finally  had  his  first  grand  mal  attack  with  tongue- 
biting  and  passing  of  urine.  Thereafter  in  the  next  four 
years  he  had  about  a  dozen  grand  mal  attacks.  He  did  poorly 
under  any  form  of  sedative  treatment,  especially  at  home. 
He  had  a  restless,  roving  type  of  disposition,  and  he  was 
permitted  latitude  in  self-direction.  He  had  vagabonded 
through  different  parts  of  the  country  on  several  occasions 
and  was  finally  allowed  to  go  into  the  Northwest,  where  he 
took  up  railroad  engineering  and  became  a  sort  of  prospect- 
ing free  lance  in  hydraulic  work  (developing  water  power 
for  railroad  companies) .  His  memory,  which  before  he  took 
up  this  life  had  steadily  grown  poorer,  improved;  his  dilap- 
idated habits  of  life  began  to  mend;  and  his  attacks  became 
less  frequent,  and  finally  ended.  However,  with  the  extra 
stress  of  forced  work  in  surveying  under  a  captious  and 
critical  "boss"  he  had  one  grand  mal  attack  some  three 
years  ago.  The  steady  increase  of  mental  stress  and  har- 
assment leading  up  to  this  recurrence  was  quite  classic  of  its 
kind.  Since  this  time  he  has  kept  himself  well  within  the 
limitations  of  his  capacity  of  endurance  and  has  been  quite 
well.  In  a  recent  communication  he  states  that  he  now 
knows  what  he  must  do  to  remain  well  and  he  intends  to 
keep  well  by  leading  the  ' '  right  kind  of  life. ' '  From  being 
a  rather  morose,  solitary  individual,  sensitive  and  irritable 


123 

and  egoistic,  he  has  steadily  widened  his  fields  of  interest 
and  vital  contact  with  his  fellows  and  is  a  fairly  good 
"mixer,"  as  well  as  an  expert  autochrome  photographer 
in  what  he  terms  "  God's  country." 

We  may  summarize  this  case  by  saying  we  have  here  a 
boy  with  a  not  very  intense  epileptic  makeup,  who  under 
the  stress  of  a  too  rigid  and  demanding  school  and  home 
life  developed  epileptic  reactions  of  a  mild  type.  Under  a 
freer  life  of  spontaneous  interests  he  quickly  recovered  from 
his  seizure  reactions,  but  when  the  stress  again  became  too 
severe  at  17  years  of  age,  a  definite  grand  mal  epilepsy  en- 
sued and  continued  till  a  broad  hygienic  life  was  instituted 
in  a  new  environment.  Even  under  this  life  regime  a  re- 
lapse occurred  when  too  much  stress  was  again  superimposed. 
I  may  say  that  although  at  present  this  young  man  shows  a 
full  arrest  of  his  disorder,  the  latter  might  be  reinvoked 
should  he  become  indifferent  toward  objectivating  fully  his 
keen  egoistic  personality  into  a  healthful  life  about  him  and 
also  should  he  permit  too  great  a  mental  stress  to  develop. 

Case  II  is  a  boy  of  14  years,  an  only  child,  whose  epi- 
lepsy developed  at  8.  After  a  definite  course  of  treatment 
and  a  cessation  of  attacks  for  nearly  two  years,  he  relapsed, 
but  has  been  placed  once  more  on  the  road  to  permanent 
arrest.  The  father's  makeup  was  of  the  classic  epileptic 
type  yet  he  never  had  convulsive  seizures;  when  a  young 
child  he  had  a  tantrum  which  did  not  cease  until  his  mother 
had  given  him  her  Easter  bonnet,  whereupon  he  tore  it  to 
bits  with  the  greatest  satisfaction.  All  the  father's  family 
were  stubborn,  egotistical  and  had  bad  tempers;  they  showed 
much  psychic  dilapidation  and  deterioration  before  middle 
age.  Their  mother  had  never  believed  in  discipline,  and  all 
her  children  followed  their  free  bent  in  behavior  and  conduct. 

The  mother  of  our  patient  is  a  keen,  quick,  resourceful 
woman;  she  has  found  it  almost  impossible  to  understand 
the  physical  and  mental  incapacity  for  quick  and  easy  adap- 
tation which  her  son  has  shown  in  the  home  and  school  life. 

Our  patient  walked  at  18  months  and  began  talking  rather 
late,  at  2  years.  He  was  a  crying,  difficult  baby.  He  en- 
tered public  school  at  7  but  did  poorly  there,  being  inordi- 


124 

nately  slow  and  inattentive,  and  at  the  end  of  two  years  he 
was  removed  on  account  of  ' '  anemia  and  nervousness. ' '  At 
10  he  attended  private  school,  but  nervousness  and  attacks 
caused  his  removal. 

The  first  epileptic  attack  came  on  after  a  period  of  pro- 
longed mental  stress  in  keeping  up  with  his  English  classes. 
One  morning  while  hurrying  to  get  off  to  catch  a  train,  he 
complained  of  dizziness  and  immediately  fell  into  a  severe 
grand  mal  attack.  Attacks  followed  this  first  one  at  fairly 
regular  intervals  of  every  two  or  three  months  until 
January,  1914,  after  which  time  he  had  no  attacks  for  two 
years. 

In  his  early  boyhood  he  was  stubborn  and  quietly  egotis- 
tical, and  set  out  rather  determinedly  to  win  his  own  way. 
When  reprimanded  he  was  apt  to  sulk.  Not  having  an 
agile  mind  or  body  it  was  difficult  for  him  to  get  into  good 
social  contact  with  the  school  life.  He  would  sit  inactive, 
day-dream,  and  engage  in  vague  childish  speculations  which, 
as  he  said,  fairly  compensated  him  "  for  the  things  he  did 
not  get  out  of  school."  Just  before  the  first  attack  not  only 
had  school  grown  distasteful,  but  he  thoroughly  disliked 
the  badgering,  nagging  teacher,  who  insistently  urged  him  to 
conform  to  the  routine  of  the  class.  He  became  listless, 
easily  irritated,  and  "  withdrew  into  himself  "  He  then  be- 
gan to  play  less  freely  and  spontaneously  with  other  children. 
While  the  first  attack  slackened  the  pace  at  school,  he  still 
easily  grew  listless,  tired,  and  dawdled  on  all  occasions,  tak- 
ing hours  to  dress.  He  was  quite  rigid  and  nonadaptive 
even  in  simple  things;  the  slightest  misplacement  of  his  be- 
longings bothered  him  greatly.  At  the  time  he  came  under 
my  care,  some  three  months  before  the  arrest  of  attacks,  it 
was  easily  seen  that  his  interest  in  life  had  flagged,  and  his 
school  and  home  adaptations  were  steadily  growing  poorer. 

First,  he  was  taken  from  school  and  given  a  free  restful 
life  of  open-air  activities.  As  the  tension  gradually  lessened 
he  began  to  pick  up  games  and  sports  that  appealed  to  him, 
and  finally  to  read  books  of  adventure.  He  was  encour- 
aged to  take  up  music  and  to  practice  what  he  liked.  As 
his  interest  quickened,  his  application  grew  apace,  and  he 


125 

coordinated  better.  Finally  he  was  able  to  ride  a  wheel 
and  to  ice-skate.  He  became  more  tactful  and  obedient 
without  seeming-  to  smother  an  inward  resentment  as  for- 
merly, and  instead  of  withdrawing  when  reprimanded  he 
now  was  fairly  agile  in  finding  substitutive  reactions  to 
get  square  with  situations.  He  soon  began  to  generate  a 
spontaneous  interest  in  mechanics;  this  showed  him  the 
necessity  of  gaining  a  better  general  education,  and  helped 
him  to  take  up  the  latter  with  more  zest  than  ever  before. 

After  eighteen  months  of  training  treatment  and  in  the 
absence  of  any  seizure  phenomena  it  was  decided  to  allow 
him  to  return  to  public  school,  which  was  done  for  a  full- 
time  attendance  without  the  physician's  knowledge.  He 
went  back  at  the  full-time  work  with  the  old  dislike,  although 
he  was  only  six  months  behind  the  grade  of  his  age.  Things 
would  have  gone  fairly  well,  perhaps,  if  he  had  had  some 
special  tutoring  or  a  little  more  consideration  from  the  teach- 
ers, who,  it  must  be  said,  are  often  prone  to  be  rather 
merciless  upon  a  backward  pupil.  He  was  still  poor  in  Eng- 
lish and  mathematics,  and  although  he  would  have  liked  to 
engage  in  sports  after  school,  the  extra  time  required  for  his 
studies  gave  him  little  opportunity.  The  lack  of  a  full 
amount  of  time  to  play,  once  not  cared  for,  now  became 
very  annoying,  and  it  was  often  difficult  to  get  him  to  his 
meals  when  out  playing  with  the  boys.  The  school  work 
gradually  grew  more  severe;  in  addition  to  English  and 
mathematics,  in  which  he  stood  poorly,  he  strove  to  gain  a 
standing  in  geography  which  would  enable  him  to  enter  the 
final  examinations.  An  attack  finally  occurred  on  Decem- 
ber 26  (1915).  Since  this  time  the  school  life  has  again 
been  readjusted,  and  there  have  been  no  attacks  up  to  the 
present  time. 

First  of  all  we  have  in  this  boy  the  makeup  in  which  seiz- 
ure reactions  were  induced  by  a  too  stressful  demand  at 
school.  When  he  was  withdrawn  from  this  difficulty  and 
placed  in  an  ideal  environment  with  a  chance  to  develop 
spontaneous  interests,  he  became  responsive  and  began  fully 
to  adapt  himself  to  a  proper  physical  and  mental  adoles- 
cence.    But   when    he   was   again   thrown    into  the  same 


126 

difficulties  he  broke  as  he  did  at  first.  He  is  now  once  more 
quite  well  adjusted  in  an  environment  comparable  to  that 
which  brought  about  the  first  arrest  two  years  ago. 

It  is  interesting  to  note  that  while  his  many  paternal  rela- 
tives had  the  epileptic  character  in  a  great  measure,  they 
probably  did  not  become  frankly  epileptic  because,  either 
by  chance  or  design,  the  grandmother  permitted  them  to  es- 
cape many  of  the  stubborn  difficulties  in  behavior  and 
conduct  which  no  doubt,  unpleasantly  antisocial  as  they  ap- 
peared, really  seem  to  have  allowed  her  children  to  escape  a 
worse  consequence  had  they  been  held  rigidly  to  an  exact 
discipline,  as  in  the  grandchild,  the  boy  under  report. 

Case  III  is  that  of  a  boy  11  years  of  age  whose  grand 
mal  epilepsy  has  been  in  arrest  for  five  years.  He  had 
attacks  usually  in  a  series  of  two  to  eight  or  ten,  and  had 
at  least  three  or  four  status  periods,  in  one  of  which  he  had 
150  grand  mal  attacks  in  a  single  day,  attended  by  delirium 
and  high  fever  (103°).  There  was  no  distinct  nervous 
disorder  in  the  family,  but  all  the  father's  relatives  had  the 
epileptic  character  in  various  degrees  of  severity.  They 
were  stubborn,  wilful,  had  tantrums  and  rages,  and  com- 
mitted acts  of  impulsive  violence.  They  were  fisher  folk 
and  at  times  had  passed  through  a  definite  lawless  career. 
Our  patient  was  an  only  child.  He  had  one  convulsion  at 
dentition.  He  was  a  crying,  stubborn,  difficult  child.  He 
attended  school  for  three  months,  his  first  trial,  at  five  years 
of  age.  It  was  not  only  difficult  for  him  to  apply  himself 
while  there  but  he  was  absolutely  incorrigible  and  could 
not  sit  still  in  the  classroom.  Even  now  when  taught  pri- 
vately he  is  able  to  study  but  an  hour,  and  thereafter  must 
be  allowed  to  play  and  do  as  he  likes.  He  was  always 
quick  and  impulsive  and  extraordinarily  overactive.  For 
instance,  in  one  of  the  half-hour  private  consultations  with 
the  mother  he  was  allowed  the  freedom  of  a  private  estate; 
during  this  time  he  picked  nearly  all  of  the  flowers  from 
the  private  flower  beds,  stoned  all  the  pigeons  from  the 
dovecote,  killed  a  cat,  broke  a  barn  door,  broke  a  whip, 
and  smashed  a  child's  cart.  Additional  minor  destructions 
gradually  came  to  light.     The  mother  thought  these  defects 


127 

in  behavior  were  not  particularly  unusual;  she  still  believed 
her  boy  to  be  only  a  little  less  tractable  than  others  of  his 
age.  Coupled  with  his  unbounded  egotism  he  was  very 
sensitive  and  when  reprimanded  often  cried  himself  to 
sleep  even  after  the  mildest  chastisement.  He  always  had 
to  be  the  centre  of  any  group  in  the  family  or  neighborhood 
circle.  He  never  played  any  game  in  which  he  could  not 
be  the  leader.  All  during  his  early  life  he  had  violent 
tantrums  and  was  so  irritable  that  his  parents  could  not 
talk  aloud  when  he  wished  to  go  to  sleep. 

On  close  investigation  of  this  crass  egoistic  and  super- 
sensitive boy,  one  finds  he  was  treated  with  absolutely  none 
of  the  ordinary  child  discipline.  While  it  was  possible  for 
him  to  endure  the  demands  of  home  life  with  rages  and 
tantrums,  when  these  later  had  to  be  repressed  at  school 
he  could  not  subordinate  these  crude  individualistic  ten- 
dencies; first  he  grew  listless,  then  more  irritable  and  finally 
broke  out  into  an  uncontrollable  temper,  was  punished  and 
sent  home.  As  his  mother  said,  "I  don't  know  what 
seemed  to  fret  and  irritate  him  so;  while  he  was  home  a?iy- 
thing  he  wanted  to  play  with  we  tried  to  get  him.  Of  course 
going  to  school  those  three  months  must  have  started  his 
trouble.'"  His  first  grand  mal  attack  came  on  one  night 
after  a  particularly  exasperating  day  at  school,  but  he  had 
been  steadily  growing  more  irritable  and  run  down  for 
a  month  before.  After  the  first  attack  he  still  continued  at 
school  with  all  its  steadily  accumulating  annoyances  until 
a  month  later  when  he  had  five  grand  mal  attacks  in  one 
night;  since  that  time  he  has  not  gone  to  school.  After  the 
series  of  attacks,  which  frequently  began  on  one  side  of  the 
body  or  the  other,  he  had  exhaustion  palsy  for  several  days 
in  parts  most  convulsed.  After  the  status  of  150  attacks 
the  palsy  did  not  disappear  for  a  week.  Before  all  the 
series    of    attacks    he   was   unusually    irritable,    as    if  he 

could  not  stand  things. ' '  He  would  be  harder  to  manage, 
was  very  fretful,  and  "nothing  seemed  to  go  right."  But 
after  an  attack  he  would  be  quite  cheerful  and  agreeable, 
and  he  acted  as  if  he  "had  gotten  rid  of  things." 
After  a  score  or  more  of  attacks  had  occurred  following  the 


128 

second  occurrence  of  his  disorder  he  was  entirely  removed 
from  study  at  school  as  well  as  at  home;  his  adenoids  were 
removed  and  a  course  of  active  sedation  with  bromides 
followed  without  cessation  of  attacks.  He  then  came  under 
a  still  freer  removal  from  irritative  surroundings  and  all 
medication  for  the  disease  as  such  was  discontinued.  He 
was  allowed  to  do  just  as  he  pleased,  to  go  and  come  with 
his  father  in  the  fishing-  boats  as  he  liked.  In  a  few  weeks 
the  attacks  began  to  subside  but  he  still  was  very  irritable; 
little  or  nothing  still  seemed  to  precipitate  tantrums  and 
rages,  but  the  latter  were  not  so  severe  or  prolonged.  As 
his  mother  said,  "He  no  longer  threw  things  or  assaulted 
others  with  his  fists  and  teeth." 

His  first  spontaneous  interest  in  his  environment  was  in 
the  management  of  a  boat  at  6  years  of  age.  Then  the 
attacks  began  to  subside.  He  worked  furiously  at  learning 
to  row  and  to  handle  the  sails  on  a  boat  until  he  was  abso- 
lutely exhausted,  whereupon  he  would  lie  quietly  on  the 
beach  or  fall  asleep  in  the  "net  bin  "  in  the  fishery.  Often 
he  was  so  ' '  dead  with  sleep ' '  that  he  would  be  carried 
home  and  put  to  bed  without  waking  and  without  supper. 
Gradually  the  tantrums  and  rages  were  brought  under  the 
control  of  the  will  and  he  could  then  be  reasoned  with;  he 
began  to  ask  to  be  taught  simple  reading,  writing  and 
arithmetic;  but  he  wanted  only  so  much  of  these  studies 
as  he  found  immediately  necessary  for  him  to  know  in  order 
to  carry  on  his  practical  understanding  of  the  fishing 
industry,  and  any  knowledge  which  he  considered  super- 
fluous to  meet  this  requirement  made  him  restless,  irritable 
and  impatient.  Soon  after  he  began  to  read  fairly  well,  he 
contracted  the  "catalogue  habit. "  He  also  developed  an 
interest  in  almanacs  as  they  gave  him  knowledge  by  which 
he  could  make  out  the  time  of  the  tides  and  weather  indi- 
cations for  the  fishermen.  At  8  years  he  had  gotten  so 
he  could  play  in  a  fairly  friendly  manner  with  neighboring 
children  without  "scraps,"  and  during  the  past  year  he 
has  actually  become  popular  with  some  of  the  boys,  although 
he  is  still  not  a  little  feared  for  his  former  reputation  of 
being  a  "bruiser."     In  a  recent  interview  he  says,  "Yes, 


129 

I  like  to  go  to  school  (one  hour  of  private  instruction);  I 
like  the  teacher;  but  I  am  down  around  the  river  most  of 
the  time.  I  go  fishing  with  the  men  and  boys  and  can  do 
all  the  things  most  of  them  can."  "No,  I  don't  play 
baseball  as  there  are  too  many  kids  around  (meaning  the 
game  is  too  complicated  in  teamwork  for  him  to  submit 
readily  to  the  rules  and  to  take  his  turn  at  batting).  There 
is  more  fun  up  the  street,  anyway.  I  like  to  be  with  the 
men  better"  (in  that  sort  of  group  greater  freedom  is  allowed 
him  than  there  would  be  in  a  crowd  of  boys).  "Can  I 
scrap?  Golly,  yes!  Sure,  I  can  lick  any  boy  of  my  own 
age;  yesterday  I  licked  one  13  years  old.  No,  the  boys 
don't  pick  on  me;  they  leave  me  alone."  From  this 
one  may  infer  that  there  are  still  important  principles  of 
social  adjustments  for  him  to  make  in  the  future.  From 
precise  tests  one  finds  this  boy  is  about  three  years  behind 
in  school  study,  but  this  is  not  necessarily  a  defect  as  ordi- 
narily considered  as  he  probably  possesses  that  type  of 
native  shrewdness  and  common  information  equal  to  boys 
of  his  age  if  not  in  advance  of  them.  Finally,  his  mother 
writes,  "He  is  now  more  easily  handled,  easier  to  direct, 
less  demanding  and  insistent,  and  he  daily  gains  in  docility. 
He  shows  improvement  in  conduct  all  the  time." 

Resembling  his  father  and  grandfather  in  disposition  and 
temperament,  he  is  naturally  ambitious  to  be  in  the  fishing 
business  with  them,  although  of  late  he  has  spontaneously 
become  very  much  interested  in  electricity,  and  the  workings 
of  the  wireless  in  particular.  He  has  shown  a  very  keen 
appreciation  in  reading  electrical  magazines  on  the  subject. 
However,  he- never  wants  to  read  or  be  told  any  more  of 
the  theoretical  part  of  any  subject  than  he  can  immediately 
apply  or  use.  In  closing  the  history  notes  I  may  say  that 
dietary  treatment  was  given  in  general  terms  only  and  aside 
from  an  occasional  laxative  no  medicines  were  given. 

In  a  brief  summary  we  may  say  that  we  have  here  a  boy 
of  the  extreme  classic  epileptic  makeup,  the  main  char- 
acter and  traits  of  which  seem  to  have  been  inherited  from 
the  paternal  side,  and  that,  when  the  subordination  of  the 
egoistic  tendencies  were  required  of  our  little  patient,  he 


130 

could  do  so  only  partly  and  with  exhibitions  of  tantrums, 
rages,  and  the  like.  Finally,  when  he  had  to  make  the 
next  social  adaptations,  away  from  home  in  the  school 
training  where  even  more  was  required,  he  could  not  do  so 
without  epileptic  reactions  of  a  violent  sort,  that  of  grand 
mal  seizures.  When  the  extra  social  demands  of  school 
and  its  intellectual  requirements  were  removed  he  still  con- 
tinued epileptic  both  in  character  and  behavior  independent 
of  grand  mal  attacks.  Not  until  he  found  spontaneous  in- 
terests in  boats,  fishing,  and  all  the  opportunities  such 
activities  gave  him  to  objectivate  his  individualism  did  he 
begin  to  mend  from  his  disorder.  This  boy  will  probably 
remain  well  from  the  latter  just  in  so  far  as  he  is  able  to 
gain  a  good  adaptive  and  adjustable  outlet  for  his  keen 
egoistic  desires,  or  is  able  to  submit  to  their  blocking  and 
accept  other  outlets  or  substitutes  for  them. 

Case  IV.  The  next  case  is  that  of  a  girl  now  22  years 
old  who  has  been  free  from  epileptic  reactions  for  ten  years. 
She  had  the  worst  possible  heredity,  including  alcoholism, 
insanity,  feeblemindedness  and  epilepsy  in  either  one  or 
both  parental  families.  She  was  born  a  rather  weak,  puny 
child  and  continued  so  to  her  tenth  year.  Her  epileptic 
attacks,  grand  mal  and  petit  mal  in  character,  occurred  at 
10  years  of  age.  They  continued  at  irregular  intervals  for 
two  years,  since  which  time  she  has  had  no  evidence  of  her 
disease  as  such. 

The  circumstances  surrounding  the  first  grand  mal  attack 
at  10  were  as  follows:  She  had  been  in  a  girls'  camp;  the 
food  was  rather  badly  cooked  and  served,  and  our  patient 
took  great  exception  to  this  as  well  as  the  fact  that  she  had 
to  work  in  a  garden  a  mile  from  the  camp.  After  this 
"hurry  up  "  work  in  the  sun  she  was  compelled  to  go  to 
the  gymnasium  for  routine  exercises  which  she  disliked  in- 
tensely; then  she  had  another  long  walk  up  a  steep  hill  for 
her  dinner.  She  hated  the  teachers  and  was  easily  pro- 
voked to  stubborn  resistances  at  "anything  they  said." 
She  felt  they  worked  her  too  hard,  the  work  was  monoto- 
nous and  uninteresting,  and  she  grew  to  hate  the  whole 
scheme  of  life.     However,  she  repressed  her  dislike  all  she 


131 

could  and  said  nothing  in  open  revolt.  She  then  began  to 
sleep  poorly,  looked  pale  and  drawn,  and  day-dreamed  a  good 
deal  when  she  had  the  opportunity.  Soon  she  began  to 
have  attacks  of  indigestion,  and  finally  refused  food  and 
asked  to  be  released  from  the  camp  environment.  This 
request  was  delayed  in  the  hope  that  she  might  satisfactorily 
adjust  herself.  Then  the  grand  mal  attack  occurred  and 
she  was  taken  home.  The  next  two  grand  mal  attacks 
occurred  while  at  home  under  less  stressful  circumstances, 
but  the  inability  to  adapt  herself  even  to  the  home  life  to 
which  she  had  returned  from  the  camp  was  still  in  evidence. 

It  was  noticed  at  this  time  that  our  patient  had  always  had 
a  peculiarly  difficult  mental  makeup.  She  had  had  tantrums 
as  a  child  and  early  thought  that,  being  a  member  of  a 
prominent  family,  she  didn't  have  to  like  people  "if  she 
didn't  want  to."  She  was  selfish  but  sympathetic,  kind 
hearted  but  not  altruistic.  She  could  not  cooperate  with 
others  and  was  very  stubborn  and  demanding.  As  she  now 
says,  "As  a  child  I  always  had  to  have  my  own  way." 
She  was  affectionate  toward  few  people.  She  was  irritable 
and  very  sensitive.  Her  general  interests  and  activities 
were  perfunctory  and  childlike.  She  continued  habits  of 
biting  her  finger  nails,  picking  her  face,  and  sucking  her 
finger  on  going  to  sleep  until  nearly  18  years  of  age.  She 
was  little  interested  in  athletic  sports  and  did  poorly  in 
them.  Broadly  speaking,  one  may  say  that  her  emotional 
attitude  and  behavior  were  childish,  and  even  now  she  has 
many  of  these  imperfections  of  development  which  have 
not  been  eradicated. 

Upon  this  epileptic  endowment,  which  was  making  for  a 
poorer  adaptation  to  the  growing  demands  of  puberty,  was 
suddenly  thrown  the  summer  camp  life  with  its  crude  country 
setting.  The  girl  could  not  adjust  herself  to  the  new  en- 
vironment, and  the  extra  stress  entailed  soon  produced  the 
epileptic  reactions  as  just  set  forth. 

At  first  the  treatment  was  by  drug  sedation  and  repressive 
lines  of  discipline,  but  this  sort  of  life  and  treatment  seemed 
to  deteriorate  the  girl  both  physically  and  mentally.  As 
she  now  states,  "  During  the  period  in  which  I  was  having 


132 

attacks  my  memory  was  poor  and  my  general  interests  were 
few.  During  that  summer  I  read  one  of  Dickens'  novels, 
but  can  remember  scarcely  any  of  it  now.  I  got  so  I  didn't 
care  for  anything  or  anybody." 

After  a  year's  treatment  of  the  usual  routine  sort,  our 
patient  was  removed  from  her  rather  artificial  and  monoto- 
nous city  environment  and  placed  in  the  country  to  do  just 
as  she  pleased.  In  a  few  weeks  she  generated  a  spontane- 
ous and  continued  interest  in  birds  and  flowers  and  spent 
all  her  time  in  the  open.  Then  she  underwent  a  self-educa- 
tion which  was  good  although  desultory.  It  extended  gradu- 
ally from  the  central  interest  of  bird  life  to  flowers,  trees, 
and  animal  life  in  general.  She  then  began  to  read  and 
study  about  these  subjects.  Finally  she  undertook  work 
embracing  the  care  of  flowers,  animals  and  a  vegetable 
garden.  The  latter,  which  at  one  time  had  been  so  distaste- 
ful to  her,  now  became  the  main  object  of  her  interest,  and 
this  was  due  in  no  small  part  to  the  fact  that  the  garden 
and  animals  were  her  very  own.  When  this  life  began  to 
grow  somewhat  monotonous  and  she  had  outgrown  it,  she 
was  introduced  to  travel  and  history  with  the  ultimate  object 
of  visiting  the  countries  studied.  This  was  undertaken  and 
carried  out  with  complete  success.  At  the  present  time  she 
is  a  strong,  robust,  intelligent  girl  who  has  a  variety  of 
home  and  neighborhood  interests,  duties  and  cares.  She 
is  never  tired,  listless  or  indifferent,  and  many  occupations 
once  done  poorly  are  now  completed  with  energy  and  dis- 
patch. While  the  fundamental  character  makeup  has  not 
materially  changed  (indeed,  never  greatly  changes  in  so- 
called  cured  cases;  the  voice  sign  is  still  present),  our 
former  patient  is  now  capable  of  generating  any  number  of 
spontaneous  interests.  Balked  now  and  then  by  a  too  cen- 
sorious relative,  she  is  adroit  in  avoiding  open  conflicts  and 
assumes  fairly  well  the  control  and  management  of  all  her 
own  business  affairs.  One  can  not  help  seeing  in  such  a 
girl  the  possibility  of  a  reestablishment  of  the  epileptic  re- 
actions should  some  unforseen  circumstance  block  or  shear 
away  the  spontaneous  interests  plus  a  renewed  imposition 
of  an  intensive  mental  or  emotional  stress.     However,  at 


133 

present  the  permanency  of  an  arrest  or  cure  in  such  an  in- 
dividual would  seem  fairly  well  assured.  It  is  interesting 
to  note  that  the  relatives  in  this  instance  as  well  as  in  the 
case  to  follow  are  firmly  of  the  belief  that  the  "cure  "  was 
brought  about  by  simple  physical  hygiene  and  that  the 
gradually  improved  mental  adaptations  were  of  decidedly 
less  consequence  than  the  selection  of  this  or  that  particular 
article  of  diet.  This  attitude  is  prejudicial  to  the  patient's 
ultimate  welfare  and  relatives  should  be  gradually  educated 
to  the  broader  biologic  view  of  the  patient's  treatment. 

Case  V  is  that  of  a  young  man  now  20  years  old  who 
was  epileptic  for  five  years,  and  who  has  been  free  from  any 
epileptic  reactions  for  six  years.  There  is  an  epileptic  and 
neuropathic  inheritance  from  the  father's  family.  The 
paternal  grandfather  was  a  sharp,  aggressive  antisocial  in- 
dividual. He  had  violent  outbreaks  of  temper  and  seemed 
never  to  be  able  to  control  them.  The  father  had  the  same 
mental  makeup  but  under  the  grandfather's  training  learned 
to  handle  and  control  it  better.  The  mother  comments  that 
our  patient  ' '  has  much  the  same  temperament  as  the  father 
but  controls  himself  much  better  than  either  the  grandfather 
or  father;  although  he  has  grown  lately  to  express  himself 
more  freely,  it  is  not  a  purely  destructive  willfulness  but  he 
goes  ahead  to  show  he  is  in  the  right."  The  mother  adds 
in  reference  to  her  own  makeup,  ' '  Once  in  a  while  I  have 
a  temper;  as  a  child  I  had  a  furious  one,  and  would  get 
angry  enough  to  knock  a  person  down.  I  now  have  it 
under  control.  I  got  the  better  of  it  by  gradually  making 
up  my  mind;  I  used  to  be  punished,  and  that  made  me  very 
much  worse.  If  I  were  shut  out  of  the  kitchen,  for  in- 
stance, I  would  go  into  a  tantrum.  If  anyone  questioned 
whether  I  was  telling  the  truth  I  would  fly  into  a  rage. 
They  used  to  tease  me  a  good  deal  just  to  start  my  temper. 
I  would  take  a  book  and  throw  it.  That  lasted  until  I  was 
about  10  years  old." 

Our  patient  was  born  a  rather  weak  child.  He  was  a 
"lively,  active  infant"  and  a  restless,  crying  baby.  He 
required  being  ' '  taken  up  a  lot, ' '  was  rocked  a  great  deal  and 
as  soon  as  he  was  asleep  and  placed  in  his  crib,  would  im- 


134 

mediately  awaken  and  cry  to  be  taken  up  again.  His  first 
attack  of  epilepsy  came  on  at  10.  He  had  already  found 
it  hard  to  study,  and  to  concentrate  his  mind.  He  then 
began  to  "develop  "  a  temper.  He  became  very  sensitive, 
stubborn  and  set  in  ideas  relative  to  dress  and  food.  He 
said  little,  but  in  getting  him  to  adapt  himself  to  the  daily 
demands  of  living  the  mother  felt  she  was  "up  against  a 
brick  wall."  The  repressed  and  inhibited  attitude  of  the 
epileptic  period  of  the  boy's  career  is  well  shown  in  that  the 
clash  between  the  father  and  son  used  to  be  met  by  the  son's 
sulking  and  grumbling.  His  mother  states,  "He  acted  as 
though  he  were  crushed  or  had  a  sense  of  smothered  resent- 
ment, but  since  he  has  recovered  from  his  attacks  he  holds 
up  his  head  and  answers  with  spirit  if  he  thinks  his  father's 
remarks  are  unjust,  and  then  the  whole  matter  is  disposed 
of  in  short  order.  Formerly  he  felt  hurt  and  angry  when 
criticized;  now  he  takes  all  things  in  an  amused  manner 
and  often  laughs  at  absurd  demands."  Just  before  his 
first  attack  he  often  said  he  felt  under  a  great  deal  of  pres- 
sure at  school  and  was  much  hurt  by  the  sharp  criticism  of 
the  father  when  he  did  poorly  at  school.  He  began  to  look 
pale,  lethargic  and  "day  dreamy."  He  "braced"  him- 
self against  the  stress  of  home  and  school  and  finally  broke 
down  completely  in  a  series  of  attacks. 

The  grand  mal  attacks  were  often  12  or  14  daily;  he  once 
had  a  status  attack  with  temperature  and  several  days  of 
mental  and  physical  prostration  following  it.  His  natural 
characteristics  gradually  increased  upon  him  "whether  he 
had  attacks  or  not  "  (he  was  free  from  attacks  for  a  year) 
until  he  became  a  morose,  irritable,  stubborn  pedantic 
invalid.  A  sedative  treatment  of  a  very  intensive  sort 
seemed  to  increase  the  attacks  and  render  him  too  stupid  to 
sit  up.  He  was  so  drugged  that  he  hallucinated  and 
suffered  from  extreme  bromism. 

First  the  sedatives  were  gradually  withdrawn,  the  diet 
made  simple  and  he  was  given  free  eliminative  treatments 
of  salines,  colonic  flushings,  etc.  Under  a  simple  hygienic 
physical  regime  the  number  and  intensity  of  attacks  were 
reduced  but   were  not  removed   altogether;  not  until   he 


135 

began  to  take  a  spontaneous  interest  in  camp  life,  away 
from  a  too  solicitous  parental  care  and  discipline,  did  he 
show  an  improved  mental  attitude  and  freedom  from  epilep- 
tic reactions  of  the  "  absence  "  type.  Although  he  kept  up 
some  of  the  physical  care  routine,  baths,  naps,  diet,  etc., 
he  got  entire  satisfaction  in  the  manual  and  industrial  train- 
ing school  which  he  asked  to  attend.  Gradually  he  became 
more  self-directive  in  his  study  and  work  and  began  to  plan 
his  own  education  and  activities.  He  soon  began  to  ex- 
pand his  interest  in  his  father's  business,  a  part  of  which 
he  succeeded  in  getting  under  his  own  control  and  manage- 
ment. Slowly  he  began  to  pick  up  better  mental  attitudes 
toward  sports  and  boy  and  girl  associates.  He  can  stand 
joking  and  is  as  free  and  agile  mentally  as  the  average  boy 
of  his  age.  The  voice  sign  still  persists.  He  says,  "if 
people  oppose  me,  I  hold  to  my  own  opinion  pretty  defi- 
nitely. I  think  I  could  have  even  more  liberties  and  still 
keep  my  health.  About  five  years  ago  mother  had  me  pretty 
well  under  her  control,  but  I  didn't  notice  it;  I  didn't  know 
what  a  good  time  was  then.  I  got  pretty  well  bored  being 
around  with  the  chickens  but  didn't  mind  it  so  much.  It  was 
more  the  gardening  I  disliked.  I  don't  think  I  minded  the 
routine  and  mother's  attention  then,  because  I  didn't  seem 
to  have  so  much  energy  and  I  really  didn't  know  what  a 
good  time  was.  At  present  I  don't  want  to  modify  my  diet. 
I  really  do  pretty  nearly  everything  I  want  now,  and  never 
have  much  irritation  within  the  past  two  or  three  years  even 
though  I  am  not  able  to  do  things.  I  like  camp  pretty 
well.  I  belonged  to  a  military  company  there,  and  am  now 
considered  a  member  of  the  First  Regiment." 

The  mother  was  encouraged  to  allow  her  son  to  go  to 
camp  and  enlarge  his  personal  freedom  as  he  seemed  a 
little  irritable  and  faultfinding;  in  camp  he  led  a  free  life, 
and  mixed  in  with  men  and  boys.  He  ate  everything,  in- 
cluding mince  pie  and  bacon,  and  gained  in  weight  while 
there.  He  took  long  jaunts  after  which  he  would  return  to 
the  camp  quite  fresh  while  the  other  men  felt  fatigued. 

To  summarize,  we  have  here  a  young  man  who  probably 
had  a  double  neuropathic  inheritance  of  the  epileptigenic 


136 

constitution  and  who  broke  into  severe  and  frequent  epilep- 
tic reactions  of  an  intensive  sort  as  soon  as  the  school  and 
social  demands  became  too  onerous.  When  he  was  placed 
upon  a  physically  hygienic  plan  of  treatment  minus  the 
unusually  large  doses  of  bromides,  he  began  to  mend,  but, 
as  shown,  this  plan  was  not  sufficient — not  until  he  was 
given  a  proper  outlet  of  his  physical  and  mental  activities 
in  healthy  spontaneous  interests  did  he  cease  having  epilep- 
tic reactions.  It  seems  fairly  conservative  to  say  that  he 
will  remain  well  so  long  as  this  mental  and  physical  regime 
endures. 

It  is  interesting  to  note  that  at  least  four  of  these  cases 
under  report  had  as  bad  a  neuropathic  heredity  as  it  is  pos- 
sible to  imagine.  Indeed,  I  venture  to  state  that  the 
majority  of  arrested  cases  are  recruited  from  the  ranks  of 
such  epileptics.  May  it  not  possibly  be  due  to  the  fact  that 
the  epileptic  reactions  in  such  are  but  the  more  intensive 
expressions  of  their  natural  inborn  temperament  and,  as 
other  bad  mental  traits,  such  as  tempers  and  tantrums,  are 
more  easily  socialized,  and,  indeed,  are  the  only  ones  that 
can  be  ?  * 


*  In  connection  with  the  foregoing  case-reports  I  may  briefly  cite  a  rather 
novel  case  of  arrested  epilepsy  in  a  dog.  Several  years  ago  a  skye  terrier,  prob- 
ably between  six  months  and  a  year  old.  was  rescued  from  bad  surroundings 
in  the  congested  district  of  Suffolk  Street  in  New  York  City  where  the  puppy 
was  in  abusive  hands.  He  had  been  having  many  attacks  of  what  seemed  to 
be  grand  mal  epilepsy.  He  was  taken  to  the  country  where  for  several  months 
occasional  fits  occurred,  but  under  the  influence  ot  better  surroundings  and 
kindly  care  the  dog  grew  strong  and  well  and  the  fits  ceased  so  that  for  years 
the  dog  never  had  any  more  attacks.  He  was  a  great  out-of-doors  animal  and 
never  could  be  held  even  in  a  wagon  but  loved  to  run  with  the  horse  ■whenever 
the  family  who  owned  him  went  anywhere.  On  such  trips  he  would  race  over 
the  fields,  hunting  woodchucks  or  rabbits,  becoming  nearly  dead  with  heat.  It 
used  to  annoy  his  owner  greatly  to  have  him  go  on  these  driving  trips  because 
whenever  a  watering  trough  was  approached  the  dog  would  swim  blissfully  in 
the  trough  and  consequently  the  water  would  not  be  fit  for  the  horse  to  drink 
from  the  dust  depo.Mted  by  the  terrier.  He  showed,  like  all  skye  terriers,  a 
great  fondness  for  the  water  and  when  warm  often  ran  off  to  the  river  to  swim 
and  cool  off  and  drink.  He  has  never  had  any  more  epileptic  attacks.  (Data 
furnished  me  by  Dr.  Edward  L.  Hanes,  Rochester,  N.  Y.) 


137 
Section  VII. 

SOME  THERAPEUTIC  SUGGESTIONS  ON  THE  MENTAL  THER- 
APY OF  ESSENTIAL  EPILEPSY  DEDUCED  FROM  ANALYSIS 
OF  THE  MATERIAL  OF  THIS  CLINICAL  STUDY. 

It  is  interesting  to  note  that  the  modern  therapy  of  epi- 
lepsy has  many  heritages  from  the  past.  Two  rather  recent 
therapeutic  experiments  have  contributed  the  greater  part  of 
our  present  day  attempts  at  the  treatment  of  the  disorder. 
The  first  had  its  advent  with  Lay  cock's  introduction  (1851) 
of  the  bromides  as  the  ideal  sedative  treatment  for  epilepsy. 
I  venture  to  say  this  therapy,  while  having  important  and 
distinctive  advantages,  has  done  more  to  obscure  the  nature 
and  pathology  of  the  disorder  than  any  other  factor  of  re- 
cent appearance.  For  more  than  half  a  century  at  least, 
the  sedative  treatment  of  epilepsy  with  bromides  has  pre- 
vailed, and  despite  every  encouragement  to  look  upon 
epileptic  therapy  in  a  more  rational  light,  the  bromides  still 
usurp  first  place  in  any  general  plan  of  treatment. 

An  historical  resume  of  the  evil  effects  of  bromide  seda- 
tion would  cast  shame  on  medical  thought  and  practice  of 
this  period.  During  the  past  two  decades,  however,  a  more 
rational  therapeutic  theory  has  been  making  slow  progress 
against  the  sedative  conception  of  treatment.  This  phys- 
ical therapy,  of  hydrotherapy,  diet,  cleansing  enemas,  and 
a  detailed  plan  of  work  and  exercise,  is  the  principle  of  the 
latter  advance. 

Still  more  recently  we  see  a  generally  recognized  effort  to 
introduce  a  rational  psychologic  therapy  for  epilepsy.  One 
may  say  that  this  is  really  not  new,  and  is  in  accord  with 
the  modern  conception  of  mental  hygiene  and  the  more  pre- 
cise interpretation  of  the  nature  and  treatment  of  the 
psychoneuroses  and  psychoses.  It  is  simply  a  careful  effort 
to  understand  the  makeup  of  the  individual  epileptic  and 
the  mental  mechanism  of  his  disorder,  and  to  apply  broad 
yet  specific  principles  of  treatment.  In  making  a  special 
plea  for  this  type  of  therapeutic  approach,  the  fact  is  not 
lost  sight  of  that  sedatives  and  physical  therapy,  partic- 
ularly the  latter,  are  not  without  value.     We  wish  merely  to 


133 

insist  on  the  limitations  of  this  kind  of  therapeutic  theory. 
The  enlarged  view  will  be  more  rational  and  also  more  hu- 
mane, yielding-  not  a  little  of  value  in  the  way  of  a  broader 
psychologic  and  sociologic  conception  of  this  disorder.  It 
must  also  contribute  its  share  of  enlightenment  on  many  a 
similar  problem  in  adjacent  fields  of  mental  therapeutics. 

Undoubtedly  the  treatment  of  the  primary  and  fundamen- 
tal makeup  of  the  epileptic  must  be  our  main  concern  as  it 
is  a  defect  which  antedates  the  seizure  phenomena  for  years. 
Next  in  importance  for  treatment  are  the  epileptic  reactions 
shown  in  behavior  and  conduct  disorders,  which  when  care- 
fully looked  for,  can  almost  always  be  found  in  a  case  of 
the  essential  disease.  These  latter  symptoms  are  of  daily 
occurrence  in  the  potential  epileptic  and  often  give  the  phy- 
sician and  relatives  most  concern  even  after  a  frankly 
convulsive  epilepsy  has  become  firmly  and  enduringly  estab- 
lished. Finally,  as  has  been  shown  in  the  preceding  sections, 
and  elsewhere  by  other  investigators,  the  seizures  themselves 
often  follow  episodes  of  stress  and  disappointment  which 
seem  to  precipitate  the  attacks.  These  need  to  be  given 
more  attention  in  future  comprehensive  plans  of  treatment. 
A  certain  degree  of  mental  deterioration  in  the  frank  epi- 
leptic is  a  natural  corollary  or  sequence  of  the  epileptic 
character  when  care  is  not  exercised  to  correct  this  tendency, 
and  my  own  case  studies  abundantly  illustrate  this  point. 
It  would  seem,  indeed,  that  the  diagnosis,  treatment,  and 
prognosis  of  idiopathic  epilepsy  can  be  properly  made  in 
future  only  by  taking  into  strict  account  the  degree  and  kind 
of  primary,  character  endowment  of  the  epileptic,  and  its 
modifiability  under  a  system  of  training,  together  with  an 
analysis  of  the  seizure  phenomena.  Though  this  statement 
makes  the  seizure  phenomena  distinctly  of  secondary  mo- 
ment, a  similar  view  has  been  more  or  less  tacitly  assumed  by 
good  clinicians  of  the  past  as  cited  in  the  beginning  of  this 
clinical  study.  To  establish  proper  principles  for  the  treat- 
ment of  epilepsy,  epileptologists  must  cease  to  give  their 
attentions  entirely  to  the  occurrence  of  individual  attacks 
and  their  treatment  as  such.  When  this  is  done,  and  only 
then,  shall  we  be  in  a  position  to  make  a  just  estimate  of  the 


139 

extent  and  character  of  the  disease  and  formulate  a  com- 
prehensive plan  of  treatment.  As  a  pure  drug  therapy  for 
epilepsy  already  savors  of  quackery,  so  should  a  purely 
physical  therapy  grow  more  and  more  to  be  regarded  in  the 
same  light. 

Sufficient  clinical  experience  is  now  at  hand  for  us  to  out- 
line more  definitely  the  mental  therapy  of  the  essential 
disorder.*  It  will  be  remembered  that  the  usual  makeup  of 
the  potentially  epileptic  child  is  one  of  egocentricity,  emo- 
tional poverty,  morbid  sensitiveness,  and  an  instinctive 
inability  to  take  on  the  adaptive  social  training  as  does  the 
normal  child  in  the  home  and  school.  A  morbid  exhibition 
of  this  latter  defect  is  shown  in  the  display  of  rages  and  tan- 
trums. Such  children  should  have  special  training  from 
earliest  infancy,  and  particularly  by  someone  specially  gifted 
for  the  task.  Often  this  is  best  done  by  someone  other  than 
the  parents.  So  soon  as  the  keen  individualism  of  these 
children  comes  into  contact  with  an  exacting  or  unyielding 
environment,  it  is  expressed  in  rages  and  tantrums.  Great 
tact  is  necessary  to  size  up  the  factors  of  each  tantrum  epi- 
sode and  judge  how  they  may  be  properly  handled.  At  one 
time  the  child  may  be  sidetracked  by  directing  his  interest 
into  another  channel;  at  another  he  may  be  completely  ig- 
nored throughout  the  entire  tantrum,  especially  if  the  child 
be  too  observant  of  the  effect  his  conduct  has  on  the  family. 
One  should  be  sure  not  to  offer  bribes  or  rewards  for  a  res- 
toration of  proper  conduct.  Often  such  concessions  are  the 
first  irreparable  beginnings  of  a  downfall  of  government  and 
discipline.  If  the  child  is  to  be  diverted  to  some  other  in- 
terest, this  should  always  be  supplied  early  and  before  any 
severe  repressive  measure  is  brought  to  bear.  In  these  ex- 
hibitions of  a  balked  desire,  one  should  look  upon  the  child's 
psychic  activity  as  a  continuously  outflowing  stream  of  in- 
terest unfortunately  thwarted,  which  should  not  be  dammed 

*I  do  not  mean  to  underrate  the  importance  of  chemotoxic  and  endocrinic  re- 
search in  epilepsy.  A  rational  therapy  based  upon  reasonably  demonstrated 
results  as  such  studies  should  be,  will  probably  give  us  ultimate  enlightenment 
upon  the  "why"  of  the  disorder.  For  the  present,  however,  an  interpretive 
therapy  can  be  provided  upon  the  "  how  "  of  the  genetic  symptomatology  of  the 
disease,  along  psychotherapeutic  lines  which  can  not  help  but  be  of  immediate 
practical  value. 


140 

or  blocked  any  more  than  an  active  mountain  stream.  One 
should  always  be  sure  of  having  the  alternative  at  hand 
before  the  main  issue  is  repressed  to  the  slightest  degree.  In 
the  most  difficult  children  it  is  best  to  teach  the  child  to 
place  his  own  inhibition  on  his  bad  conduct  and  direct  his 
attention  to  the  new  object  without  coercion  or  too  much  out- 
side persuasion.  No  tantrum  episode  should  be  allowed  to 
pass  without  a  friendly  and  sympathetic  review  of  all  the 
circumstances  which  led  up  to  the  disorder.  Tireless  and 
tactful  restatement  is  necessary  of  the  great  personal  loss  the 
child  himself  has  suffered  in  consequence.  To  be  fully  effec- 
tive, every  opportunity  for  right  conduct  at  the  tantrum 
periods  must  be  fully  coupled  up  with  the  actual  personal 
disadvantage  the  child  suffers  from  his  acts.  The  issues  in 
question  must  be  plain  and  simple,  comparable  with  the  de- 
gree of  mental  development  to  which  the  child  has  attained. 
The  explanatory  period  is  often  at  hand  long  before  one 
ordinarily  thinks  it  is  possible.  For  instance,  several 
children  whom  I  have  known  have  been  given  these  simple 
talks  in  their  third  year,  with  much  success.  The  plea  of 
personal  motive  to  right  conduct  in  such  children  may  be 
ultimately  fortified  by  altruistic  and  social  advantages,  but 
these  should  never  form  the  central  core  or  main  issue  of 
training  against  tantrum  episodes  in  their  early  manifesta- 
tions. The  absence  of  altruistic  instincts,  or  their  very 
rudimentary  character  in  these  children,  is  quite  character- 
istic of  the  type.  As  regards  the  everyday  or  general 
behavior  of  these  children,  a  stiffening  of  the  will  or  a 
broadening  of  emotional  inhibition  should  not  be  undertaken 
too  early  or  too  intensively.  Such  children  are  usually  in- 
ordinately slow  in  adopting  simple  or  mildly  difficult 
adaptations,  and  in  consequence  fatigue  unbelievably  soon. 
I  know  a  child  who  at  5  or  6  years  of  age  can  not  bear  even 
the  slightest  coercive  direction  for  more  than  an  hour  or  two 
without  complete  rest  and  frequent  day  naps.  Children  of 
this  type  do  not  always  show  their  exhaustion  in  simple 
ways;  they  often  look  pale  and  haggard,  pupils  are  dilated, 
or  they  grow  lethargic,  sit  and  day  dream  or  slowly  mount 
on  a  thin  crest  of  hilarity  easily  broken  by  ' '  squalls  ' '  of  ap- 


141 

parently  meaningless  crying;  or  they  may  show  gross  motor 
incoordination  and  make    unusually  precise  and  rigid  de- 
mands of  deportment  on  the  part  of  their  playmates.     The 
trained  observer  gets  to  know  these  varied  signs  of  fatigue 
and  is  often  able  to  lower  their  nervous  tension  tactfully  by 
quieter  play.     Under  one  pretext  or  another  these  children 
may  be  persuaded  to  seek  rest  of  their  own  accord,  after  the 
higher  level  of  their  activity  has  been  gradually  lowered.    A 
tantrum  is  not  far  distant  in  the  bored  or  tired  egoistic  child, 
and  running  counter  to  his  playmates  is  one  of  the  common- 
est means  which  he  takes  to  break  the  intolerable  situation. 
However,  one  usually  feels  that  to  give  so  much  attention 
to  the  crises  of  personal  conflict  which  the  epileptic  child 
manifests,  is  again  to  really  miss  the  main  point  of  the  train- 
ing treatment.     The  fault  is  quite  comparable  in  a  way  with 
the  obsessive  attention  physicians,  nurses  and  relatives  com- 
monly give  to  the  epileptic  fit  in  the  frankly  established 
disorder  itself.     Long  before  the  child  displays  tantrums, 
one  finds  much   slighter  but  equally  obtrusive  manifesta- 
tions of  mal-adaption  to  the  simple  processes  of  life.     Often 
these  children  must  be  slowly  and  carefully  inured  to  the 
unpleasant  demands  of   hunger  and  fatigue,   a    failure  of 
which  is  frequently  expressed  in  the  restless  crying  baby. 
One  must  more  slowly  accustom  such  children  to  the  ham- 
pering and  unpleasant  contact  of  the  clothing,  which  often 
forces  them  into  stereotyped  positions.     The  desire  for  rid- 
dance of  clothing  is  so  much  a  part  of  the  instinctive  life  of 
the  epileptic  child  that  many  seizures  of  the  milder  sort  oc- 
curring in  the  later  life  of  such  individuals  are  attended  by 
automatic    movements  of   disrobing,  which  acts  are  often 
performed  in  a  childlike  manner.     The  potentially  epileptic 
child  should  have  less  insistent  demands  placed  upon  him, 
and  for  shorter  periods  of  time  than  other  children.     His 
preference  for  certain  types  of  dress  should  also  be  taken 
into  account  and  yielded  to  so  far  as  practicable.    An  equally 
wise  attitude  may  be  assumed  toward  the  bath  and  diet.    If 
left  somewhat  to  self  selection  and   direction  in  many  of 
these  matters,  such  difficult  children  much  more  readily  and 
safely  mend  their  ways.     The  same  principle  also  applies  to 


142 

the  type  and  character  of  play.  The  lesson  derived  from 
other  children  doing  the  conventional  thing,  most  tactfully 
supplies  a  corrective  influence  which  a  parent  or  nurse  may 
not  exert.  Frequently  an  incentive  to  reasonable  conduct 
once  planted  by  the  right  kind  of  associates  bears  more  fruit- 
ful results  than  many  and  oft-repeated  injunctions  from  the 
child's  elders.  A  similar  principle  for  handling  the  more 
benign  types  of  conduct  disorders  in  the  normal  child  has 
long  been  recognized  and  practiced  with  advantage. 

One  may  safely  say  that  the  method  by  which  the  child 
secures  its  first  adaptations  to  hunger  and  fatigue,  and  to 
social  adjustments  of  work  and  play  with  its  fellows,  should 
be  a  guide  for  the  proper  after-training  of  the  potentially 
epileptic  child.  Sufficient  data  are  now  at  hand  to  indicate 
that  this  primary  endowment  of  makeup  is  probably  always 
hereditary  in  the  potential  epileptic,  and  it  often  rests  with 
us  whether  we  shall  allow  it  to  develop  to  its  logical  con- 
clusion in  an  outspoken  epilepsy  or  by  our  attitude  and 
manner  of  handling  it  prevent  such  development.  A  com- 
plete change  of  the  makeup  is  probably  beyond  our  power, 
but  the  modification  of  it  should  be  our  main  concern  in  the 
future,  if  we  wish  to  conserve  such  children  from  following 
an  epileptic  career  in  later  life. 

One  may  think  that  the  infantile  and  child  life  are 
without  stress  and  conflicts.  However,  one  need  but  to 
remember  what  Preyer  has  shown,  that  the  unpleasant 
feelings  are  greatly  in  the  ascendency  all  during  this  child- 
hood period.  Even  with  the  most  careful  nursing,  diet, 
ventilation,  and  regulation  of  temperature  of  the  air  and 
bath,  under  the  most  favorable  surroundings,  it  is  not  granted 
the  average  child  to  pass  many  days  without  suffering. 
How  much  more  painful,  then,  must  these  discomforts  be 
to  such  a  supersensitive  child  as  we  are  considering. 
Granting  the  above,  what  may  one  propose  on  the  dynamic 
or  positive  side  in  the  proper  adaptation  of  the  epileptic 
child?  For  this  task  one  needs  to  study  the  child  with 
greatest  care.  If  the  parents  are  incapable  of  a  sympathetic 
understanding  of  what  the  child  is  striving  for  and  his  main 
trends  of  interest,  then  the  work  must  be  entrusted  to  others 


143 

possessing  this  gift.  A  system  of  ethics  can  easily  be  built 
up  around  almost  any  line  of  activity  the  child  may  select. 
One  may  note  its  presence  in  all  races,  even  in  those  whose 
life  activities  are  most  antipodal  to  our  own.  It  is  the  atti- 
tude of  approach  toward  one's  specific  surroundings  that 
matters, — not  necessarily  the  things  themselves.  If  our 
type  of  child  chooses  either  a  practical  or  an  imaginative 
approach,  then  he  should  be  encouraged  to  find  a  proper 
healthful  adjustment  to  that  kind  of  life.  The  incessant 
clamoring  of  the  child  for  variety  and  novelty  of  interests 
is  but  the  natural  demand  that  is  his  birthright — to  see  as 
many  of  the  different  facets  of  life  as  possible.  Our  concern 
is  not  to  limit  these  novelties,  but  to  see  that  the  child  shall 
have  a  thoroughness  of  experiencing  them.  The  very 
completeness  with  which  the  difficult  child  may  be  made  to 
do  this  is  the  safest  protection  against  day  dreams,  lethargies 
and  like  abreactions  from  his  work  and  play  leading  to  bore- 
dom and  irritability, — the  forerunners  of  rages  and  tantrums. 
To  establish  at  the  earliest  possible  moment  a  self- directive 
government  in  the  potential  epileptic  child  should  be  our 
aim.  The  end  sought  is  really  to  have  him  learn  to  penalize 
himself  and  adjust  his  own  capabilities  and  desires  to  reality. 
Frequent  psychotherapeutic  talks  relative  to  his  difficulties 
are  of  greatest  moment,  and  these  can  be  undertaken  only 
by  someone  in  full  sympathy  and  confidence  with  such  a 
child,  and  for  good  results  one  must  carefully  chose  the 
correct  time  and  place.  An  instance  in  point  is  the  little 
boy  (No.  6)  casually  mentioned  on  page  185  of  this  clinical 
study  (Psychiatric  Bulletin,  April,  1916). 

In  brief,  then,  the  foregoing  embraces  the  main  outlines 
of  some  of  the  more  important  suggestions  for  the  proper 
mental  therapy  of  the  potentially  epileptic  child  in  the  home 
before  the  school  age  is  reached.  The  proper  inculcation 
of  a  good  system  of  nursery  ethics  is  by  far  the  most  impor- 
tant object  in  training  such  children. 

While  the  scholastic  training  for  all  children  must  rest 
somewhat  upon  the  same  common  grounds,  the  goal  to  be 
won  for  the  education  of  the  epileptic  youth  must  be 
arranged  to  suit  his  peculiar  makeup.      The  methods  of 


144 

attaining  it  are  quite  distinct  and  special.  For  instance, 
where  there  is  an  intellectual  defect  coincident  with  an 
epileptic  makeup  the  problem  is  to  educate  this  type 
of  individual  somewhat  as  if  he  were  feebleminded. 
Even  if  this  is  done,  sooner  or  later  there  will  be  a 
distinct  outcropping  of  the  peculiar  epileptic  instincts 
that  would  demand  a  considerable  modification  of  the 
school  system;  but  while  this  class  forms  a  large  part  of 
institutional  charges,  numerically  it  is  not  so  important  in 
the  general  run  of  epileptic  children.  The  former  may  show 
further  handicaps  of  mental  arrest  or  even  mental  deterio- 
ration, forcing  one  to  modify  the  school  training  very  con- 
siderably. Often  the  purely  intellectual  training  has  to  be 
entirely  omitted  and  the  whole  time  given  over  to  tutoring 
the  epileptic  youth  in  social  behavior.  In  other  words,  the 
school  training  for  epileptics  should  be  intensively  individ- 
ualistic and  constantly  elastic.  The  very  monotony  which 
the  feebleminded  enjoy  in  any  scholastic  training,  is 
poisonous  to  the  soul  of  the  epileptic.  The  latter  requires 
novelty  and  a  wide  range  of  educational  appeal.  More- 
over, in  a  large  number  of  epileptic  youths  the  intellect,  as 
such,  suffers  but  little  or  no  impairment,  and  the  educational 
training  which  these  individuals  need  is  little  different  from 
that  which  is  ordinarily  given  to  normals,  except  that  it 
includes  adjustment  to  work  and  adaptations  along  ethical, 
moral  and  social  lines. 

On  the  whole  one  may  say  it  is  a  great  mistake  to 
approach  the  problem  of  educational  training  for  the 
epileptic,  in  its  broadest  sense,  on  the  old  ground  that  he  is 
only  a  little  less  retarded  than  the  feebleminded,  because 
in  reality  his  primary  fault  is  his  egoistic  trend  and  an 
emotional  poverty.  These  abnormalities  affect  his  environ- 
mental rapport  and  often  he  suffers  from  a  lack  of  intellec- 
tual stimulus  because  of  a  weakened  attachment  to  reality. 
Simply  because  he  is  mentally  retarded  is  no  reasom  for  his 
education  being  placed  on  the  plane  of  that  for  the  feeble- 
minded. The  same  might  be  said  of  the  deteriorated 
dementia  praecox  patients  whose  psychometric  test  brings 
them  within  the  middle  range  of  the  feebleminded.     If  the 


145 

schooling  is  like  that  for  the  feebleminded  it  should  be 
possible  to  modify  its  routine  so  as  to  make  it  adjustable  to 
the  demands  of  the  epileptic  character.  The  retarded 
epileptic  has  such  an  irregular  mental  age  level  at  best  that 
he  is  not  often  capable  of  doing  well  in  any  large  class 
teaching  as  does  the  feebleminded. 

The  differences  between  the  feebleminded  and  the  epileptic 
are  by  no  means  essentially  purely  academic.  They  are 
sufficiently  common  and  far  reaching  to  compel  the  atten- 
tion of  educators,  and  they  should  be  particularly  recognized 
by  those  who  plan  to  place  the  two  classes  together  in  one 
institution.  Should  this  plan  be  adopted  to  any  large  extent 
in  this  country,  the  innate  differences  in  makeup  and  men- 
tality of  the  two  classes  should  be  recognized,  and  proper 
classification  made  in  the  schools.  The  laisser  faire  attitude 
of  slightly  modifying  a  feebleminded  school  to  fit  the  epileptic 
should  not  be  allowed  to  prevail. 

It  is  easy  enough  to  see  that  epileptic  youths  who  have 
very  frequent  attacks  can  make  little  use  of  any  system  of 
regular  intellectual  training  because  of  the  nature  of  their 
attacks  and  the  amount  of  acute  mental  disturbance 
entailed.  The  attacks  prevent  a  consecutive  attendance  at 
school,  hence  much  of  the  education  is  rendered  useless  on 
account  of  the  break  in  its  continuity. 

We  find  a  system  of  educational  training  of  most  value 
in  epileptic  youths  who  have  infrequent  attacks,  and  have 
a  fair  intellectual  endowment  as  well  as  ability  to  generate 
directed,  and  finally  spontaneous,  interests.  Primarily  the 
colonization  of  epileptics  means  most  to  these  individuals. 
It  supplies  a  continually  interesting  and  varied  environ- 
ment with  all  the  possibilities  of  modification  from  season 
to  season,  so  that  monotony  and  boredom  can  be  avoided. 

After  the  above  rather  negative  views  as  to  why  the 
epileptic  should  not  be  given  the  treatment  of  the  feeble- 
minded type,  let  us  consider  the  positive,  dynamic  aspect 
of  the  proper  treatment. 

The  system  of  education  in  the  schoolroom  must  be  an 
essential  and  integral  part  of  the  occupational  life  of  the 
epileptic,   whether  he  recovers  from    his  epilepsy  or  not. 


146 

What  he  needs  is  to  have  his  educational  training  coupled 
up  with  the  occupations  in  which  he  is  engaged  and  which 
he  cares  about.  For  instance,  those  who  are  interested  in 
agriculture  should  have  a  system  of  book  instruction  and 
class  work  that  will  make  for  a  further  elaboration  and 
understanding  of  all  the  daily  duties  grouped  around  this 
particular  type  of  interest.  It  is  obvious  that  the  maximum 
of  school  training  shall  be  concrete  rather  than  of  an 
abstract  nature,  and  along  the  lines  in  which  the  patient 
exhibits  the  keenest  interest  and  most  distinct  capabilities. 
Abundant  illustrations  are  furnished  in  foregoing  case 
histories  to  show  that  the  type  and  manner  of  school  train- 
ing should  be  properly  adapted  to  the  peculiar  makeup  of 
the  individual  child. 

The  greater  part  of  what  has  already  been  said  applies 
to  the  training  of  those  children  who  may  also  show  frank 
epileptic  seizures  during  early  childhood.  The  actual  pro- 
tection of  the  mental  and  physical  integrity  of  the  frankly 
epileptic  child  becomes  doubly  necessary  when  attacks 
have  once  commenced.  First  of  all  the  child  usually  needs 
to  be  withdrawn  from  the  average  school  which  often  fur- 
nishes the  stress  that  is  too  much  for  him.  A  period  of 
care-free  existence  should  then  be  maintained  sufficiently 
long  for  the  little  patient  to  recover  his  mental  balance  and 
the  proper  regulation  of  physical  health.  The  pallor, 
nervousness,  disturbed  sleep  and  like  symptoms  are  usually 
removed  quickly  under  such  a  let-alone  treatment.  At  this 
stage  the  real  trial  begins,  because  from  this  point  on  we 
must  have  two  motives  in  operation  in  handling  the  patient: 
first,  to  remove  all  the  too  stressful  situations  which  the 
patient  has  reacted  away  from  in  the  attacks;  and  secondly, 
to  begin  a  careful  system  of  training  in  slowly  accustoming 
the  patient  to  types  of  stress  which  he  must  get  used  to  if 
he  is  to  make  a  proper  adaptation  in  life  when  he  has 
recovered  from  his  more  gross  epileptic  manifestations. 
The  reconciliation  of  these  two  motives  in  a  training  treat- 
ment calls  for  the  greatest  discernment  and  tact.  Often 
this  can  be  initiated  only  away  from  home — especially  away 
from  either  a  too  harsh  and  unsympathetic  discipline,  or  a 


147 

too  inconstant  and  overindulgent  one.  I  have  succeeded 
fairly  well,  however,  in  training  the  least  neurotic  of  the 
two  parents  in  many  instances  to  undertake  the  proper 
training-  treatment  for  their  epileptic  child.  But  the  per- 
sonal sacrifice  entailed  is  very  great,  even  though  the 
training  treatment  progresses  satisfactorily. 

There  is  a  parallel  in  the  training  treatment  of  the  frankly 
established  epileptic  and  that  of  the  epileptic  child  before 
the  disease  has  become  established.  With  the  former, 
however,  efforts  must  be  redoubled  and  placed  on  a  more 
adult  plane.  One  should  not  rest  content  with  the  removal 
of  a  stress  from  the  life  of  the  epileptic  youth,  for  this  is 
only  a  preliminary  treatment.  If  this  let-alone  principle 
only  is  followed,  the  situation  which  will  soon  develop  will 
be  but  little  less  intolerable  for  all  concerned  than  the 
original  condition.  If  left  to  himself,  the  frank  epileptic 
soon  occupies  himself  with  day-dreaming,  lethargies,  and 
all  sorts  of  idle  dissipations,  which  in  their  turn  often  beget 
more  epileptic  reactions. 

One  should  study  how  best  one  may  help  the  epileptic 
individual  to  objectivate  his  interest  in  work,  study  and 
play  in  accordance  with  his  ability.  To  carry  this  into 
effect,  the  closest  scrutiny  of  his  emotional  and  intellectual 
interests  is  necessary.  His  environment,  which  in  most 
instances  may  have  been  reduced  in  social  demands,  ought 
still  to  offer  sufficiently  varied  outlets  from  which  he  must 
choose  a  number  of  interests  and  amusements.  Probably 
no  greater  mistake  is  made  than  to  tell  epileptic  individuals 
to  betake  themselves  to  the  country  and  then  allow  the 
matter  to  end  there.  Many  epileptics  almost  at  once  have 
an  increased  number  of  attacks  and,  what  is  still  worse, 
begin  to  deteriorate  mentally  and  emotionally  through  lack 
of  proper  stimulus.  There  must  be  a  certain  novelty  in  the 
occupations  and  amusements,  and  not  a  few  to  select  from; 
hence  the  importance  of  epileptics  being  in  a  country 
environment  not  too  dissimilar  to  that  to  which  they  have 
been  accustomed, — only  the  tempo,  as  it  were,  is  to  be 
reduced.  Some  of  the  large  public  colonies  for  epileptics  are 
richly  supplied  with  such  potential  advantages  but  unfortu- 


148 

nately  for  economic  reasons  alone  a  number  of  highly  trained 
and  gifted  attendants  and  physicians  are  not  at  hand  to  assist 
these  more  sluggish  epileptics  to  get  the  proper  start  in  con- 
genial work.  Lacking  personal  direction  and  attention, 
many  an  epileptic  manufactures  his  own  interests  only  after 
a  long  time,  or  not  at  all. 

All  frankly  pronounced  epileptics  are  doubly  handicapped 
by  their  natural  antisocial  tendencies  as  well  as  by  the 
epileptic  seizures  themselves.  Such  a  temperament  is  a 
direct  hindrance  to  the  epileptic  taking  up  a  healthy  inter- 
est in  any  life  offered  him.  In  the  absence  of  a  spontane- 
ous interest,  the  remnants  of  former  ones  must  be  pieced 
together  or  new  ones  induced.  This  can  be  effected  only 
by  actually  living  in  close  contact  with  the  daily  lives  of 
the  patients,  assisting  and  encouraging  them  to  start  the 
cold  and  uninviting  task  anew  each  day.  Often  before 
work  and  study  can  actually  be  put  in  operation  the  epilep- 
tic individual  must  be  given  many  kindly  explanatory  talks 
concerning  the  treatment,  the  common-sense  view  taken  of 
his  disorder,  and  the  method  planned  for  its  riddance. 
These  talks  have  to  be  endlessly  varied,  and  simplified  to 
the  individual's  understanding.  The  friendly  association 
which  many  another  neurotic  or  psychotic  may  have  with 
the  nurse  and  physician  plays  but  little  part  in  dealing  with 
epileptics.  The  very  nature  of  their  makeup  precludes  this, 
and  the  treatment  is,  therefore,  at  times  most  disheartening. 
Of  course  the  unlikability  of  such  epileptic  individuals, 
and  the  physician's  and  nurse's  failure  to  transfer  their  own 
deep  interest  to  them,  are  proverbial.  Still  the  task  must 
be  done  in  spite  of  the  mutual  unstable  and  weakened  trend 
of  sympathetic  interest.  Until  a  satisfactory  talk  makes 
the  problem  clear  to  the  patient,  little  can  be  done.  Even 
when  the  new  regime  is  fully  inaugurated  it  may  fail  in  a 
single  day  and  the  whole  process  of  confidence  and  assur- 
ance must  be  reinvokedthe  next.  A  few  gifted  individuals 
may  succeed  in  the  role  just  detailed,  but  may  fail  in  the 
next  step  of  putting  the  theory  into  practice.  The 
general  dislike  of  the  epileptic  to  perform  sustained  labor 
day   by   day   is   well  known,   and  the  faithful  attendant 


149 

must  himself  participate  in  the  activities  outlined  and  in 
most  instances  must  take  the  lead  until  such  time  as  it  can 
be  borne  without  direction  and  guidance.  Probably  the 
motive  back  of  the  advice  given  in  foreign  text-books 
that  the  epileptic  should  live  in  a  country  clergyman's 
family  is  to  gain  for  such  invalids  the  varied  and  sustained 
cooperative  interest  of  the  family.  Unfortunately  in  this 
country  either  the  clergy  are  not  inclined  to  undertake  such 
work,  or  they  are  too  illy  equipped  by  nature  to  cope  with 
such  a  delicate  humanitarian  problem.  What  is  even 
more  unfortunate,  our  country  practitioners  are  often 
but  little  better  qualified  to  understand  the  far-reaching 
importance  of  taking  epileptic  individuals  under  their 
personal  supervision.  To  be  sure,  it  implies  an  intense 
preoccupation  in  the  minutiae  of  the  lives  of  such  persons, 
but  the  issues  can  not  otherwise  be  met  if  the  profession  is 
to  assume  the  obligations.  Perhaps  a  broader  understand- 
ing of  the  purpose  of  modern  mental  hygiene  will  remedy 
this  lack  in  the  future.  If  so  it  will  be  to  the  lasting 
advantage  of  epileptics  as  well  as  many  another  mental 
invalid. 

Just  as  we  made  note  of  the  inadequacy  of  considering 
only  the  tantrum  of  the  potentially  epileptic  child,  neglect- 
ing the  whole  issue  of  understanding  and  correcting  the 
lives  of  such  children,  so  we  may  reiterate  here  the  useless- 
ness  of  exclusive  concern  in  the  epileptic's  life  at  the  time 
of  or  shortly  before  his  attacks.  To  do  so  is  to  fail  in  a 
considerable  number  of  instances,  to  lose  a  proper  evalua- 
tion of  the  mental  precipitating  factors  of  fits,  as  well  as  to 
lose  sight  of  the  broader  principles  concerned  in  the  proper 
mental  treatment  of  the  individual  case.  The  immediate 
factors  often  found  to  make  for  attacks  have  already  been 
illustrated  by  charts  in  a  preceding  section;  suffice  it  to  say 
here  that  such  chartings  are  often  of  the  utmost  practical 
moment  in  shaping  a  training  treatment.  By  avoiding 
these  stressful  factors  and  substituting  other  lines  of  activity 
and  interests,  one  may  introduce  an  effective  mental  therapy 
in  many  cases.  There  is  rarely  a  case  in  which  intelligent 
care  in  this  direction  may  not  signally  aid  one  in  formula- 


150 

ting  a  progressive  treatment.  Not  a  few  therapeutic 
generalizations  have  been  laid  down  in  an  article  already 
published* 

Conclusions :  One  may  summarize  the  results  of  this 
clinical  study  of  essential  epilepsy  as  follows  : 

(1)  There  exists  a  more  or  less  definite  type  of  consti- 
tutional makeup  in  epileptics  which  has  long  been  recog- 
nized by  many  able  neurologists  and  psychiatrists  and  this 
defect  accounts  in  no  small  part  for  the  so-called  "predis- 
position "  to  the  disease — a  term  in  common  use  to-day. 
The  essential  defects  of  instincts  are  egocentricity,  super- 
sensitiveness,  an  emotional  poverty,  and  an  inherent  defect 
of  adaptability  to  normal  social  life  in  its  broadest  signifi- 
cance. The  main  defect  is  an  inheritable  one.  This 
makeup  is  the  primary  or  original  mental  endowment  of 
the  potentially  epileptic  individual.  It  is  accentuated  and 
made  the  more  obvious  by  the  further  advance  of  the  disease 
only  when  seizures  develop.  It  is  then  often  spoken  of 
as  the  "  mental  stigma  "  of  the  disease.  The  attacks  are 
not  solely  responsible  for  epileptic  deterioration,  but  the 
seizures  are  themselves  symptoms  and  exhibitions  of  the 
deteriorating  disorders.  The  seizures  do  not  always  indi- 
cate the  progress  and  degree  of  deterioration  in  any  given 
case  ;  i.  e.,  the  number  and  severity  of  fits  in  a  given  case 
may  not  be  an  index  to  the  amount  of  deterioration,  nor 
may  one  postulate  the  severity  of  seizure  reaction  in  a  par- 
ticular case  by  the  type  of  deterioration. 

(2)  The  precipitating  mental  factors  that  often  seem  to 
bring  about  epileptic  reactions  in  a  potential  epileptic, 
which  range  all  the  way  from  simple  disorders  of  conduct 
to  definite  seizures,  are  types  of  stress  and  annoyance, 
causing  a  loss  of  spontaneous  interest,  and  an  intensive 
regression  to  day-dreaming,  lethargies  and  somnolence. 
The  attack  occurs  at  the  final  break  of  a  too  severe  tension, 
and  psychologically  may  be  viewed  as  an  intense  reaction 
away  from  the  intolerable  irritation,  a  regression  to  a  primi- 
tive mentality  comparable  to  that  of  infancy  or  intra-uterine 
life. 

*  Clark,  "  Some  therapeutic  suggestions  derived  from  the  newer  psychology 
cal  studies  upon  the  nature  of  essential  epilepsy,''  Medical  Record,  March  4, 1916. 


151 

(3)  The  therapeutic  suggestions  for  a  mental  therapy 
in  essential  epilepsy  would  be  to  overcome,  by  proper  train- 
ing and  education,  the  earliest  beginnings  of  epileptic 
reactions  in  childhood.  More  particularly  should  the  train- 
ing concern  itself  with  the  eradication,  as  far  as  possible,  of 
the  defective  instincts  shown  in  egocentricity,  supersensi- 
tiveness  and  rigidity  of  adaptation  to  the  home  and  com- 
munity. This  is  best  brought  about  by  (a)  reducing  and 
limiting  the  undue  stress  of  the  environment;  by  (b)  steadily 
teaching  the  child  adaptation  to  various  types  of  stress  so 
that  he  may  ultimately  be  able  to  live  a  fairly  normal  life 
without  exhibition  of  such  grosser  epileptic  reactions  as  are 
shown  in  the  seizures  of  his  disorder,  (c)  The  epileptic 
may  be  shown  and  taught  to  find  a  spontaneous  outlet  for 
his  keen  individualistic  desires  and  thus  manufacture  his 
own  interests  in  a  heathful  environment  suitable  to  his  needs 
and  capacity. 

(4)  Even  though  many  epileptics  may  be  quite  deterio- 
rated, it  is  still  often  possible  to  train  back  their  once 
discarded  mental  interest  and  thus  restore  much  of  their 
emotional  and  mental  dilapidation.  In  the  more  favorable 
cases  great  improvement  of  the  convulsive  symptoms  occurs 
in  many  such  individuals  and  with  the  more  or  less  perma- 
nent arrest  of  the  disorder  in  not  a  few  cases.  A  series  of 
arrested  cases  of  frankly  pronounced  epilepsies  are  cited  to 
show  the  mental  mechanism  by  which  arrests  have  been 
brought  about  through  an  application  of  the  foregoing 
therapy.* 


*  I  wish  to  acknowledge  my  thanks  to  my  nurse-trainers,  and  especially  to 
Mr.  T.  E.  Uniker,  for  valuable  assistance  in  the  minute  observation  of  many  of 
the  cases  incorporated  in  this  study. 


DATE  DUE 


COLUMBIA  UNIVERSITY 


0032093535 


